Provider Demographics
NPI:1033440466
Name:MICKELSON, BRYAN K (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:K
Last Name:MICKELSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 605
Mailing Address - Street 2:
Mailing Address - City:WORLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82401-0605
Mailing Address - Country:US
Mailing Address - Phone:307-272-5368
Mailing Address - Fax:307-347-4038
Practice Address - Street 1:120 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401-3637
Practice Address - Country:US
Practice Address - Phone:307-272-5368
Practice Address - Fax:307-347-4038
Is Sole Proprietor?:No
Enumeration Date:2010-01-25
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 103TC1900X, 103TC2200X, 103TP2701X, 103TS0200X
WY#535103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool