Provider Demographics
NPI:1437234994
Name:LEPPICELLO, MITCHELL A (LICSW)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:A
Last Name:LEPPICELLO
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13393 26TH ST N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-1513
Mailing Address - Country:US
Mailing Address - Phone:651-408-5132
Mailing Address - Fax:
Practice Address - Street 1:700 COMMERCE DR
Practice Address - Street 2:SUITE 295
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-9232
Practice Address - Country:US
Practice Address - Phone:651-408-5132
Practice Address - Fax:651-735-7844
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN97631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1437234993Medicaid