Provider Demographics
NPI:1073047056
Name:MCKENZIE, KRISTAL ROSE (LADC)
Entity Type:Individual
Prefix:
First Name:KRISTAL
Middle Name:ROSE
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:KRISTAL
Other - Middle Name:ROSE
Other - Last Name:HAHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LADC
Mailing Address - Street 1:3381 GORHAM AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-4240
Mailing Address - Country:US
Mailing Address - Phone:952-926-2600
Mailing Address - Fax:
Practice Address - Street 1:3381 GORHAM AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4240
Practice Address - Country:US
Practice Address - Phone:952-926-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303641101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1972927879OtherNPI