Provider Demographics
NPI:1245855147
Name:DANIELSON, MACKENZIE SANDRA (MOT)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:SANDRA
Last Name:DANIELSON
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 DEMERS AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4100
Mailing Address - Country:US
Mailing Address - Phone:701-739-5437
Mailing Address - Fax:701-746-9198
Practice Address - Street 1:2600 DEMERS AVE STE 101
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4100
Practice Address - Country:US
Practice Address - Phone:701-739-5437
Practice Address - Fax:701-746-9198
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
MN5785225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist