=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629898317
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALASKA TELEHEALTH THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2024
-----------------------------------------------------
Last Update Date | 10/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 51137 NANOOK CIR
-----------------------------------------------------
City | NIKISKI
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99611-9318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-252-6076
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 8291
-----------------------------------------------------
City | NIKISKI
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99635-8291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-252-6076
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE OWNER
-----------------------------------------------------
Name | MAGHAN KRUZICK
-----------------------------------------------------
Credential | MS, LPC
-----------------------------------------------------
Telephone | 907-252-6076
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------