Provider Demographics
NPI:1922794221
Name:MICKELSON, CAROL RAE (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:RAE
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2985 LEXINGTON AVE N
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1915
Mailing Address - Country:US
Mailing Address - Phone:651-415-0440
Mailing Address - Fax:
Practice Address - Street 1:6 PINE TREE DR
Practice Address - Street 2:
Practice Address - City:ARDEN HILLS
Practice Address - State:MN
Practice Address - Zip Code:55112-3745
Practice Address - Country:US
Practice Address - Phone:651-639-0942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5372235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist