Provider Demographics
NPI:1639648538
Name:BOTHUN, MICHELLE ANNE (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANNE
Last Name:BOTHUN
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14663 MERCANTILE DR N
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-4559
Mailing Address - Country:US
Mailing Address - Phone:612-405-3156
Mailing Address - Fax:651-389-9492
Practice Address - Street 1:14663 MERCANTILE DR N
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:MN
Practice Address - Zip Code:55038-4559
Practice Address - Country:US
Practice Address - Phone:612-405-3156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-20
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3494106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist