Provider Demographics
NPI:1427431279
Name:MICKELSON, KATELYN ANN
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:ANN
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:ANN
Other - Last Name:TERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-328-6512
Practice Address - Street 1:100 4TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1929
Practice Address - Country:US
Practice Address - Phone:701-234-3100
Practice Address - Fax:701-234-3120
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6215103TC0700X
390200000X
ND609P103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program