Provider Demographics
NPI:1588972962
Name:MICKELSON, CYNTHIA LEANN (BA, MOTR/L)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:LEANN
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:BA, MOTR/L
Other - Prefix:MRS
Other - First Name:CYNDI
Other - Middle Name:
Other - Last Name:MICKELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BA, MOTR/L
Mailing Address - Street 1:110 2ND ST S
Mailing Address - Street 2:
Mailing Address - City:WAITE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56387-1662
Mailing Address - Country:US
Mailing Address - Phone:320-402-4401
Mailing Address - Fax:
Practice Address - Street 1:110 2ND ST S
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1662
Practice Address - Country:US
Practice Address - Phone:320-402-4401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3707225X00000X
AZ4686225X00000X
CO3127225X00000X
OR277541225X00000X
MN104887225X00000X
CA12363225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1588972962Medicare NSC