Basic Information
| Provider Information | |||||||||
| NPI: | 1588190607 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIKKELSON | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | APSW, SACIT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1550 | ||||||||
| Address2: | |||||||||
| City: | RHINELANDER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545011550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153625745 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 822 STILLWELL AVE | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549012217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153625745 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2017 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | WI | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | WI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 9240-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.