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General NPI Number Information
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NPI Number | 1508686353
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Entity Type | Organization
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Legal Business Name | AUTHENTICALLY YOU THERAPY
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Dates
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Enumeration Date | 10/16/2024
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Last Update Date | 10/16/2024
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Provider Practice Location Address
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Address Line | 3212 14TH AVE S STE 7
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City | FARGO
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State | ND
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Zip | 58103-6306
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Country | US
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Telephone | 701-318-0895
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Fax |
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Provider Business Mailing Address
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Address Line | 4707 46TH ST S APT 315
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City | FARGO
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State | ND
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Zip | 58104-9014
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Country | US
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Telephone | 701-318-0895
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | MS. GABRIELLE ELISE HAGEN
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Credential | MS, LPCC
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Telephone | 701-318-0895
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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