Provider Demographics
NPI:1568773679
Name:MICKELSON, CHARLES GLEN (CPED)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:GLEN
Last Name:MICKELSON
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 12TH AVE. NORTH
Mailing Address - Street 2:
Mailing Address - City:SOUTH ST. PAUL,
Mailing Address - State:MN
Mailing Address - Zip Code:55075-1915
Mailing Address - Country:US
Mailing Address - Phone:651-291-7000
Mailing Address - Fax:
Practice Address - Street 1:423 12TH AVE. NORTH
Practice Address - Street 2:
Practice Address - City:SOUTH ST. PAUL,
Practice Address - State:MN
Practice Address - Zip Code:55075-1915
Practice Address - Country:US
Practice Address - Phone:651-291-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-24
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist