Provider Demographics
NPI:1750184669
Name:MICKELSON, DANIEL (SAC-IT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:MICKELSON
Suffix:
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 WALKER WAY
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-1700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:903 MINERAL POINT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2970
Practice Address - Country:US
Practice Address - Phone:608-756-6564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-28
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20656-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)