Provider Demographics
NPI:1508686353
Name:AUTHENTICALLY YOU THERAPY
Entity type:Organization
Organization Name:AUTHENTICALLY YOU THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:GABRIELLE
Authorized Official - Middle Name:ELISE
Authorized Official - Last Name:HAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPCC
Authorized Official - Phone:701-318-0895
Mailing Address - Street 1:4707 46TH ST S APT 315
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-9014
Mailing Address - Country:US
Mailing Address - Phone:701-318-0895
Mailing Address - Fax:
Practice Address - Street 1:3212 14TH AVE S STE 7
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6306
Practice Address - Country:US
Practice Address - Phone:701-318-0895
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health