Provider Demographics
NPI:1568933273
Name:MATTISON, MICHELLE CHRISTINA (LMSW, LICSW)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:CHRISTINA
Last Name:MATTISON
Suffix:
Gender:F
Credentials:LMSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12900 TECHNOLOGY DR APT 220
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-2900
Mailing Address - Country:US
Mailing Address - Phone:248-252-7668
Mailing Address - Fax:
Practice Address - Street 1:762 TRANSFER RD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-4506
Practice Address - Country:US
Practice Address - Phone:517-281-8436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-07
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MI68011142091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical