Basic Information
| Provider Information | |||||||||
| NPI: | 1710053301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HITZELBERGER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 COON RAPIDS BLVD #200 | ||||||||
| Address2: | NSCC | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 58433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637843008 | ||||||||
| FaxNumber: | 7637843647 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 COON RAPIDS BLVD #200 | ||||||||
| Address2: | NSCC | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 58433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637843008 | ||||||||
| FaxNumber: | 7637843647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 01/05/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP3538 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 437709500 | 05 | MN | MEDICAID |