{
"Npi": {
"NPI": "1508686353",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "AUTHENTICALLY YOU THERAPY",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "4707 46TH ST S APT 315",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "FARGO",
"MailingAddressStateName": "ND",
"MailingAddressPostalCode": "58104-9014",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "701-318-0895",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "3212 14TH AVE S STE 7",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "FARGO",
"PracticeLocationAddressStateName": "ND",
"PracticeLocationAddressPostalCode": "58103-6306",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "701-318-0895",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "10/16/2024",
"LastUpdateDate": "10/16/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "HAGEN",
"AuthorizedOfficialFirstName": "GABRIELLE",
"AuthorizedOfficialMiddleName": "ELISE",
"AuthorizedOfficialTitle": "THERAPIST",
"AuthorizedOfficialNamePrefix": "MS.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MS, LPCC",
"AuthorizedOfficialTelephoneNumber": "701-318-0895",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QM0850X",
"TaxonomyName": "Adult Mental Health Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}