Provider Demographics
NPI:1043002595
Name:MICKELSEN, AMBER
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:MICKELSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E VENTURE WAY APT 5308
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-1205
Mailing Address - Country:US
Mailing Address - Phone:208-380-6968
Mailing Address - Fax:
Practice Address - Street 1:1500 E VENTURE WAY APT 5308
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-1205
Practice Address - Country:US
Practice Address - Phone:208-380-6968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-20
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-384181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical