Provider Demographics
NPI:1013964253
Name:MITZEL, MADONNA A (OT)
Entity Type:Individual
Prefix:MS
First Name:MADONNA
Middle Name:A
Last Name:MITZEL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 94TH AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-1992
Mailing Address - Country:US
Mailing Address - Phone:763-762-6800
Mailing Address - Fax:763-315-6685
Practice Address - Street 1:1702 E MAIN ST STE 103
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-3818
Practice Address - Country:US
Practice Address - Phone:701-415-0000
Practice Address - Fax:833-969-0195
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND929225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND51326Medicaid
ND23089OtherBCBSND
ND51326Medicaid