Provider Demographics
NPI:1447558168
Name:MICKELSON, RACHEL LYNN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RACHEL
Middle Name:LYNN
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 GRAPE RD
Mailing Address - Street 2:STE 1
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3015
Mailing Address - Country:US
Mailing Address - Phone:574-243-9370
Mailing Address - Fax:574-243-9375
Practice Address - Street 1:2410 GRAPE RD
Practice Address - Street 2:STE 1
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3015
Practice Address - Country:US
Practice Address - Phone:574-243-9370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-03
Last Update Date:2020-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042493A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical