Provider Demographics
NPI:1699315598
Name:SIVERTSON, MCKENZIE LEE
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:LEE
Last Name:SIVERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 2ND ST SE STE 1B
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-6566
Mailing Address - Country:US
Mailing Address - Phone:701-500-2690
Mailing Address - Fax:
Practice Address - Street 1:1905 2ND ST SE STE 1B
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-6566
Practice Address - Country:US
Practice Address - Phone:701-500-2690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5674104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker