Provider Demographics
NPI:1831526011
Name:MICKELSON, MARGARET GAYLE (LMFT, ATR)
Entity type:Individual
Prefix:MISS
First Name:MARGARET
Middle Name:GAYLE
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:LMFT, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-4320
Mailing Address - Country:US
Mailing Address - Phone:949-303-9053
Mailing Address - Fax:
Practice Address - Street 1:228 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-4320
Practice Address - Country:US
Practice Address - Phone:949-303-9053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCATCB 01-016101Y00000X
CAMFC35838106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA45-5044899OtherEIN