Provider Demographics
NPI:1467904342
Name:MICHAELSON, MICHELE MEI
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:MEI
Last Name:MICHAELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6333 WARREN AVE S
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-1243
Mailing Address - Country:US
Mailing Address - Phone:612-889-4013
Mailing Address - Fax:
Practice Address - Street 1:6607 18TH AVE S
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2784
Practice Address - Country:US
Practice Address - Phone:612-889-4013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3747106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist