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NPI Code Detail

MEDICARE: MACKENZIE GANGL LICSW

MEDICARE: MACKENZIE GANGL LICSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker
2101YM0800XMental Health Counselor16191MN

General Provider Information

NPI Number : 1346517786
Entity Type Code : Individual
Provider Name (Legal Business Name) : MACKENZIE GANGL LICSW
Provider Business Mailing Address
First Line : PO BOX 9859
Second Line :
City : FARGO
State : ND
Zip : 58106-9859
Country : US
Telephone Number : 701-451-4900
Fax Number :
Provider Business Practice Location Address
First Line : 823 MAPLE ST
Second Line :
City : BRAINERD
State : MN
Zip : 56401-3770
Country : US
Telephone Number : 320-584-4121
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/30/2011
Last Update Date : 10/20/2022

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Directions to “ MACKENZIE GANGL LICSW” Practice Location

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