| Doctor Name: | MYRON MICKELSON |
| NPI Number: | 1326189291 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | L.C.S.W. |
| License Number: | 2350-123 |
| Business Practice Address: | E1475 Owens Drive La Valle, WI - 539419529 |
| Business Phone Number: | 6089857187 |
| Business Fax Number: | 6089858187 |
| Mailing Address: | E1475 Owens Drive, LA VALLE |
| State: | WI |
| Postal Code: | 539419529 |
| Phone Number: | 6089857187 |
| Fax Number: | 6089858187 |
| NPI Enumeration Date: | 02/12/2007 |
| NPI Last Update Date: | 07/09/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 2350-123 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |