Provider Demographics
NPI:1184108771
Name:MICHAELS, STEPHANIE M (PSYD, LP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:MICHAELS
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2320 MARSHALL AVE APT 309
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6085
Mailing Address - Country:US
Mailing Address - Phone:651-334-3710
Mailing Address - Fax:
Practice Address - Street 1:219 SE MAIN ST STE 400
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-2151
Practice Address - Country:US
Practice Address - Phone:612-886-2524
Practice Address - Fax:612-886-2538
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNLP6305103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNLP6305OtherMN BOARD OF PSYCHOLOGY