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General NPI Number Information
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NPI Number | 1407645195
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Entity Type | Individual
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Provider Name | REZA MATHEW MIKHAEIL LGSW
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Gender | Male
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Dates
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Enumeration Date | 05/01/2025
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Last Update Date | 05/01/2025
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Provider Practice Location Address
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Address Line | 13045 FALCON DR STE 100
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City | BAXTER
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State | MN
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Zip | 56425-4201
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Country | US
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Telephone | 218-829-9307
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Fax | 218-829-7649
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Provider Business Mailing Address
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Address Line | 13045 FALCON DR STE 100
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City | BAXTER
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State | MN
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Zip | 56425-4201
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Country | US
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Telephone | 218-829-9307
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 34397
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License Number State | MN
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