Provider Demographics
NPI:1891235255
Name:BROSSART, MACKENZIE LYN (LMSW)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LYN
Last Name:BROSSART
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:LYN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:135 SIMS ST STE 202
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-5148
Mailing Address - Country:US
Mailing Address - Phone:701-264-9049
Mailing Address - Fax:
Practice Address - Street 1:300 13TH AVE W STE 1
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4875
Practice Address - Country:US
Practice Address - Phone:701-227-7500
Practice Address - Fax:701-227-7575
Is Sole Proprietor?:No
Enumeration Date:2017-03-06
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5427104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No104100000XBehavioral Health & Social Service ProvidersSocial Worker