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General NPI Number Information
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NPI Number | 1902562382
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Entity Type | Individual
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Provider Name | CHAD MICKELSON DPT
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Gender | Male
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Dates
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Enumeration Date | 11/10/2021
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Last Update Date | 11/10/2021
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Provider Practice Location Address
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Address Line | 4801 VETERANS DR
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City | SAINT CLOUD
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State | MN
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Zip | 56303-2015
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Country | US
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Telephone | 320-252-1670
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Fax |
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Provider Business Mailing Address
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Address Line | 18425 BROWNS LAKE RD
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City | RICHMOND
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State | MN
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Zip | 56368-8567
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Country | US
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Telephone | 360-320-8328
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 11320
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License Number State | MN
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