Basic Information
Provider Information
NPI: 1033557152
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: IVERSEN
FirstName: MICHELLE
MiddleName: NICOLE
NamePrefix:  
NameSuffix:  
Credential: MA, LMFT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: BUCKLEY
OtherFirstName: MICHELLE
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 5
Mailing Information
Address1: 3525 MONTEREY DR
Address2:  
City: ST LOUIS PARK
State: MN
PostalCode: 554165275
CountryCode: US
TelephoneNumber: 9529939197
FaxNumber:  
Practice Location
Address1: 3525 MONTEREY DR
Address2:  
City: ST LOUIS PARK
State: MN
PostalCode: 554165275
CountryCode: US
TelephoneNumber: 9529939197
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/11/2013
LastUpdateDate: 05/31/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106H00000X2591MNY Behavioral Health & Social Service ProvidersMarriage & Family Therapist 

No ID Information.


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