Healthcare Provider Details

I. General information

NPI: 1033440466
Provider Name (Legal Business Name): BRYAN K MICKELSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2010
Last Update Date: 05/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S 17TH ST
WORLAND WY
82401-3637
US

IV. Provider business mailing address

PO BOX 605
WORLAND WY
82401-0605
US

V. Phone/Fax

Practice location:
  • Phone: 307-272-5368
  • Fax: 307-347-4038
Mailing address:
  • Phone: 307-272-5368
  • Fax: 307-347-4038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number#535
License Number StateWY
# 6
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: