Basic Information
| Provider Information | |||||||||
| NPI: | 1346517786 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANGL | ||||||||
| FirstName: | MACKENZIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9859 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581069859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014514900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 823 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | BRAINERD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564013770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205844121 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2011 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YM0800X | 16191 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.