Provider Demographics
NPI:1922168244
Name:MISUKANIS, THOMAS MICHAEL SR (PHD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MICHAEL
Last Name:MISUKANIS
Suffix:SR
Gender:M
Credentials:PHD
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Mailing Address - Street 1:7800 METRO PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1514
Mailing Address - Country:US
Mailing Address - Phone:952-876-0727
Mailing Address - Fax:952-851-9618
Practice Address - Street 1:7800 METRO PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-1514
Practice Address - Country:US
Practice Address - Phone:952-876-0727
Practice Address - Fax:952-851-9618
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2020-12-30
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Provider Licenses
StateLicense IDTaxonomies
CO1929103G00000X, 103TC0700X
MNLP3921103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN460980800Medicaid