Provider Demographics
NPI:1093226508
Name:CHRISTIANSON, GARY DENNIS (LADC)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:DENNIS
Last Name:CHRISTIANSON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 5TH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:INTERNATIONAL FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56649
Mailing Address - Country:US
Mailing Address - Phone:218-285-7029
Mailing Address - Fax:218-285-7072
Practice Address - Street 1:900 5TH ST STE 301
Practice Address - Street 2:
Practice Address - City:INTERNATIONAL FALLS
Practice Address - State:MN
Practice Address - Zip Code:56649
Practice Address - Country:US
Practice Address - Phone:218-285-7029
Practice Address - Fax:218-285-7072
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302526101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)