1215097928 NPI number — MRS. GRETCHEN SUZANNE KIRVIDA LICSW

Table of content: MARLA E GELTNER APRN-BC (NPI 1740739986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215097928 NPI number — MRS. GRETCHEN SUZANNE KIRVIDA LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIRVIDA
Provider First Name:
GRETCHEN
Provider Middle Name:
SUZANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215097928
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 397
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTER CITY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-257-5399
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7039 20TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTERVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55038-9737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-288-0332
Provider Business Practice Location Address Fax Number:
651-288-0493
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  3068 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 169876 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 205M6KI . This is a "BC BS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 4028602 . This is a "BHP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 17395900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP37279 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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