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General NPI Number Information
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NPI Number | 1568933273
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Entity Type | Individual
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Provider Name | MICHELLE CHRISTINA MATTISON LMSW, LICSW
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Gender | Female
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Dates
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Enumeration Date | 12/07/2018
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Last Update Date | 08/30/2022
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Provider Practice Location Address
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Address Line | 762 TRANSFER RD
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City | SAINT PAUL
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State | MN
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Zip | 55114-4506
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Country | US
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Telephone | 517-281-8436
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Fax |
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Provider Business Mailing Address
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Address Line | 12900 TECHNOLOGY DR APT 220
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City | EDEN PRAIRIE
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State | MN
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Zip | 55344-2900
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Country | US
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Telephone | 248-252-7668
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6801114209
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License Number State | MI
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