Provider Demographics
NPI:1164656989
Name:BACH GANSEN, LORETTA JAYNE (LADC)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:JAYNE
Last Name:BACH GANSEN
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:PARK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56470-1210
Mailing Address - Country:US
Mailing Address - Phone:218-366-9229
Mailing Address - Fax:218-237-2520
Practice Address - Street 1:515 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1210
Practice Address - Country:US
Practice Address - Phone:218-366-9229
Practice Address - Fax:218-237-2520
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300392101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1164656989OtherLADC