Provider Demographics
NPI:1710053301
Name:HITZELBERGER, MICHAEL (MA LP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:HITZELBERGER
Suffix:
Gender:M
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 COON RAPIDS BLVD #200
Mailing Address - Street 2:NSCC
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:58433
Mailing Address - Country:US
Mailing Address - Phone:763-784-3008
Mailing Address - Fax:763-784-3647
Practice Address - Street 1:425 COON RAPIDS BLVD #200
Practice Address - Street 2:NSCC
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:58433
Practice Address - Country:US
Practice Address - Phone:763-784-3008
Practice Address - Fax:763-784-3647
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3538103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN437709500Medicaid