Provider Demographics
NPI:1033557152
Name:IVERSEN, MICHELLE NICOLE (MA, LMFT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NICOLE
Last Name:IVERSEN
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:BUCKLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:301 MAIN ST W
Mailing Address - Street 2:
Mailing Address - City:NEW PRAGUE
Mailing Address - State:MN
Mailing Address - Zip Code:56071
Mailing Address - Country:US
Mailing Address - Phone:507-301-3412
Mailing Address - Fax:
Practice Address - Street 1:301 MAIN ST W
Practice Address - Street 2:
Practice Address - City:NEW PRAGUE
Practice Address - State:MN
Practice Address - Zip Code:56071
Practice Address - Country:US
Practice Address - Phone:507-301-3412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2591106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist