Provider Demographics
NPI:1316503683
Name:BOMSTAD, MCKENZIE (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:BOMSTAD
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12017 62ND ST NE
Mailing Address - Street 2:
Mailing Address - City:SPICER
Mailing Address - State:MN
Mailing Address - Zip Code:56288-9440
Mailing Address - Country:US
Mailing Address - Phone:320-266-5075
Mailing Address - Fax:
Practice Address - Street 1:411 3RD ST N
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1177
Practice Address - Country:US
Practice Address - Phone:320-253-4120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN309581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical