Provider Demographics
NPI:1639565187
Name:PAULSON, MITCHEL
Entity Type:Individual
Prefix:
First Name:MITCHEL
Middle Name:
Last Name:PAULSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 ARUNDEL ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-1701
Mailing Address - Country:US
Mailing Address - Phone:507-993-4757
Mailing Address - Fax:
Practice Address - Street 1:952 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-3014
Practice Address - Country:US
Practice Address - Phone:612-819-0556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-11
Last Update Date:2015-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101YP2500X
MN472831101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool