Provider Demographics
NPI:1003578758
Name:MASON, MIKKI K (LMFT, LADC)
Entity Type:Individual
Prefix:
First Name:MIKKI
Middle Name:K
Last Name:MASON
Suffix:
Gender:F
Credentials:LMFT, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5645 GREEN CIRCLE DR APT 200
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-9658
Mailing Address - Country:US
Mailing Address - Phone:612-532-1020
Mailing Address - Fax:
Practice Address - Street 1:9245 QUANTRELLE AVE NE
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55330-0168
Practice Address - Country:US
Practice Address - Phone:763-308-8619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304777101YA0400X
MN4150106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)