Provider Demographics
NPI:1700401379
Name:THORSON, MCKENZIE
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:THORSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 115
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:ND
Mailing Address - Zip Code:58579-0115
Mailing Address - Country:US
Mailing Address - Phone:701-220-1623
Mailing Address - Fax:
Practice Address - Street 1:7500 HIGHWAY 7 APT 462
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4153
Practice Address - Country:US
Practice Address - Phone:701-220-1623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst