=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497166516
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LYNN MIKKELSEN LCPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2014
-----------------------------------------------------
Last Update Date | 05/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 281 1ST AVE. WN
-----------------------------------------------------
City | KALISPELL
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-471-6267
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 361
-----------------------------------------------------
City | KALISPELL
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59903-0361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-471-6267
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | SWP-LCPC-LIC-5377
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------