Provider Demographics
NPI:1801506704
Name:WAXLAX, MICHAEL GRAHAM (LADC, LPCC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GRAHAM
Last Name:WAXLAX
Suffix:
Gender:M
Credentials:LADC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2031 ROWLAND RD
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-7119
Mailing Address - Country:US
Mailing Address - Phone:320-364-1300
Mailing Address - Fax:651-323-2558
Practice Address - Street 1:230 1ST ST
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1330
Practice Address - Country:US
Practice Address - Phone:218-969-1943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-01
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303086101YA0400X
MN4158101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)