Provider Demographics
NPI:1053836338
Name:MICKELSON, CHEYENNE MICHELLE (BCBA)
Entity Type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:MICHELLE
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7265 W CENTER AVE UNIT 321
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80226-2769
Mailing Address - Country:US
Mailing Address - Phone:262-325-4032
Mailing Address - Fax:
Practice Address - Street 1:2001 HOYT ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-1639
Practice Address - Country:US
Practice Address - Phone:303-759-1192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-08
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-20-44715103K00000X
ALRBT-17-35392106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty