Provider Demographics
NPI:1679274997
Name:MIKESELL, MATTHEW (PHD, CMPC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:MIKESELL
Suffix:
Gender:M
Credentials:PHD, CMPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3808 HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-4761
Mailing Address - Country:US
Mailing Address - Phone:262-313-8063
Mailing Address - Fax:
Practice Address - Street 1:7401 METRO BLVD STE 510
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-3033
Practice Address - Country:US
Practice Address - Phone:952-835-8513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6824103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling