Provider Demographics
NPI:1730524927
Name:MIKKELSON, DAVID P (LMFT)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:P
Last Name:MIKKELSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1047 VISTA PARK DR STE A
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-4362
Mailing Address - Country:US
Mailing Address - Phone:434-616-2388
Mailing Address - Fax:434-616-2344
Practice Address - Street 1:1800 COLBY DR
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-1872
Practice Address - Country:US
Practice Address - Phone:434-515-1253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-01
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717001353106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist