Provider Demographics
NPI:1487176590
Name:LANDGREN, MICHAEL JOHN (MSED, LP)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOHN
Last Name:LANDGREN
Suffix:
Gender:M
Credentials:MSED, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6425 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1675
Mailing Address - Country:US
Mailing Address - Phone:612-861-1675
Mailing Address - Fax:612-861-3446
Practice Address - Street 1:6425 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1675
Practice Address - Country:US
Practice Address - Phone:612-861-1675
Practice Address - Fax:612-861-3446
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3917103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical