Provider Demographics
NPI:1851351688
Name:SCHMITZ, MICHAEL FUKASAWA (PSYD, LP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:FUKASAWA
Last Name:SCHMITZ
Suffix:
Gender:M
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:MR 10809
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:800 E 28TH ST
Practice Address - Street 2:WASIE BUILDING, 6TH FLOOR, MR 15600
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3723
Practice Address - Country:US
Practice Address - Phone:612-863-5327
Practice Address - Fax:612-863-2596
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNLP1448103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN470315400Medicaid
MN470315400Medicaid
680001005Medicare ID - Type Unspecified