Provider Demographics
NPI:1669007043
Name:MICKELSON, RAQUEL ANN
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:ANN
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1816
Mailing Address - Country:US
Mailing Address - Phone:928-522-9474
Mailing Address - Fax:928-522-9475
Practice Address - Street 1:2920 N 4TH ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1816
Practice Address - Country:US
Practice Address - Phone:928-522-9474
Practice Address - Fax:928-522-9475
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-16678101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health