MEDICARE: DR. MATTHEW MIKESELL PHD, CMPC

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	103TC1900X	Counseling Psychologist	LP6824	MN

General Provider Information

NPI Number	:	1679274997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW MIKESELL PHD, CMPC

Provider Business Mailing Address
First Line	:	3808 HOWARD AVE
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-4761
Country	:	US
Telephone Number	:	262-313-8063
Fax Number	:

Provider Business Practice Location Address
First Line	:	7401 METRO BLVD STE 510
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55439-3033
Country	:	US
Telephone Number	:	952-835-8513
Fax Number	:

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

Provider Enumeration Date	:	03/14/2023
Last Update Date	:	03/14/2023

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