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NPI Code Detail

MEDICARE: DR. RICHARD WAYNE MICKELSEN M.D.

MEDICARE: DR. RICHARD WAYNE MICKELSEN M.D.
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
12084P0800XPsychiatry Physician5336032-1205UT
22084P0804XChild & Adolescent Psychiatry Physician5336032-1205UT

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1U002OTHERUTDESERET MUTUAL
2U003OTHERUTEDUCATORS MUTUAL
3U001OTHERUTBLUE CROSS
4U006OTHERUTINTERMOUTAIN HEALTH CARE
5U009OTHERUTCHAMPUS

General Provider Information

NPI Number : 1740250372
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. RICHARD WAYNE MICKELSEN M.D.
Provider Business Mailing Address
First Line : 1300 E CENTER ST
Second Line :
City : PROVO
State : UT
Zip : 84606-3554
Country : US
Telephone Number : 801-344-4400
Fax Number : 801-344-4225
Provider Business Practice Location Address
First Line : 1300 E CENTER ST
Second Line :
City : PROVO
State : UT
Zip : 84606-3554
Country : US
Telephone Number : 801-344-4215
Fax Number : 801-344-4225
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/25/2006
Last Update Date : 02/18/2026

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1013995471 — EDWARD LESLIE KELLY MD
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1300 E CENTER ST
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84606-3554
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1386624625 — MR. DEREK PAUL DAVIS LCSW
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84606-3554
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1265485593 — MR. ROBERT S. SPENCER APRN
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84606-3554
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