Healthcare Provider Details

I. General information

NPI: 1235959008
Provider Name (Legal Business Name): RYKKI GAGNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 MILLER TRUNK HWY STE 209
DULUTH MN
55811-4448
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW STE 110
NEW BRIGHTON MN
55112-1789
US

V. Phone/Fax

Practice location:
  • Phone: 218-524-8889
  • Fax: 218-524-8890
Mailing address:
  • Phone: 651-628-9566
  • Fax: 651-524-8890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number302530
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: