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General NPI Number Information
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NPI Number | 1679274997
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Entity Type | Individual
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Provider Name | MATTHEW MIKESELL PHD, CMPC
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Gender | Male
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Dates
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Enumeration Date | 03/14/2023
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Last Update Date | 03/14/2023
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Provider Practice Location Address
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Address Line | 7401 METRO BLVD STE 510
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City | EDINA
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State | MN
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Zip | 55439-3033
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Country | US
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Telephone | 952-835-8513
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Fax |
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Provider Business Mailing Address
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Address Line | 3808 HOWARD AVE
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City | WHITE BEAR LAKE
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State | MN
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Zip | 55110-4761
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Country | US
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Telephone | 262-313-8063
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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 | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | LP6824
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License Number State | MN
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