Provider Demographics
NPI:1407645195
Name:MIKHAEIL, REZA MATHEW (LGSW)
Entity type:Individual
Prefix:
First Name:REZA
Middle Name:MATHEW
Last Name:MIKHAEIL
Suffix:
Gender:
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13045 FALCON DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-4201
Mailing Address - Country:US
Mailing Address - Phone:218-829-9307
Mailing Address - Fax:
Practice Address - Street 1:13045 FALCON DR STE 100
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-4201
Practice Address - Country:US
Practice Address - Phone:218-829-9307
Practice Address - Fax:218-829-7649
Is Sole Proprietor?:No
Enumeration Date:2025-05-01
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN343971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical