MEDICARE: INGVILD MIKKELBORG MA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1558095067
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	INGVILD MIKKELBORG MA

Provider Business Mailing Address
First Line	:	190 W STATE ROUTE 89A # 1157
Second Line	:
City	:	SEDONA
State	:	AZ
Zip	:	86336-6135
Country	:	US
Telephone Number	:	928-567-1322
Fax Number	:

Provider Business Practice Location Address
First Line	:	3090 E CORONADO TRL # AZ86335
Second Line	:
City	:	RIMROCK
State	:	AZ
Zip	:	86335-5283
Country	:	US
Telephone Number	:	928-567-1322
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2022
Last Update Date	:	07/11/2022

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