Healthcare Provider Details

I. General information

NPI: 1740250372
Provider Name (Legal Business Name): RICHARD WAYNE MICKELSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 E CENTER ST
PROVO UT
84606-3554
US

IV. Provider business mailing address

1300 E CENTER ST
PROVO UT
84606-3554
US

V. Phone/Fax

Practice location:
  • Phone: 801-344-4215
  • Fax: 801-344-4225
Mailing address:
  • Phone: 801-344-4400
  • Fax: 801-344-4225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5336032-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number5336032-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: