Provider Demographics
NPI:1205466125
Name:PROEBSTLE, MICHAEL (MA, LPC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PROEBSTLE
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3763 DENMARK TRL W
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1010
Mailing Address - Country:US
Mailing Address - Phone:612-888-3858
Mailing Address - Fax:
Practice Address - Street 1:4141 OLD SIBLEY MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-1996
Practice Address - Country:US
Practice Address - Phone:612-888-3858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2310101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor