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General NPI Number Information
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NPI Number | 1710842687
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Entity Type | Individual
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Provider Name | KELLY JO GAG
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Gender | Female
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Dates
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Enumeration Date | 12/22/2025
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Last Update Date | 12/22/2025
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Provider Practice Location Address
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Address Line | 1221 ROSSMAN AVE
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City | DETROIT LAKES
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State | MN
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Zip | 56501-3826
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Country | US
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Telephone | 218-847-9268
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Fax |
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Provider Business Mailing Address
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Address Line | 1841 BRAINARD BLVD
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City | DETROIT LAKES
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State | MN
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Zip | 56501-7987
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Country | US
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Telephone | 218-847-9268
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 102918
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License Number State | MN
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