Provider Demographics
NPI:1558583179
Name:POINDEXTER, MICHAEL (MS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:POINDEXTER
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:POINDEXTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:1068 LAKE ST S
Mailing Address - Street 2:#109
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-2639
Mailing Address - Country:US
Mailing Address - Phone:651-982-4792
Mailing Address - Fax:651-982-6035
Practice Address - Street 1:1068 LAKE ST S
Practice Address - Street 2:#109
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-2639
Practice Address - Country:US
Practice Address - Phone:651-982-4792
Practice Address - Fax:651-982-6035
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLMFT#1308106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist