Provider Demographics
NPI:1912066952
Name:MISCHKE, JOHN BERNARD (MA LP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BERNARD
Last Name:MISCHKE
Suffix:
Gender:M
Credentials:MA LP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:480 WHEELOCK PKWY W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-4258
Mailing Address - Country:US
Mailing Address - Phone:651-489-0149
Mailing Address - Fax:651-654-7065
Practice Address - Street 1:821 RAYMOND AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1503
Practice Address - Country:US
Practice Address - Phone:651-647-0659
Practice Address - Fax:651-647-0659
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN2396103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist