Provider Demographics
NPI:1821776543
Name:GOSA, MACKENZIE ALLYN (MS)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ALLYN
Last Name:GOSA
Suffix:
Gender:F
Credentials:MS
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 233
Mailing Address - Street 2:
Mailing Address - City:BLUE RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97413-0233
Mailing Address - Country:US
Mailing Address - Phone:541-852-0899
Mailing Address - Fax:
Practice Address - Street 1:1600 UNIVERSITY AVE W STE 203
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3838
Practice Address - Country:US
Practice Address - Phone:651-645-0980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist