Healthcare Provider Details

I. General information

NPI: 1306305339
Provider Name (Legal Business Name): KANDICE LARAY GORRES LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 9TH AVE W
ALEXANDRIA MN
56308-2221
US

IV. Provider business mailing address

222 9TH AVE W
ALEXANDRIA MN
56308-2221
US

V. Phone/Fax

Practice location:
  • Phone: 320-763-3912
  • Fax: 320-763-6629
Mailing address:
  • Phone: 320-763-3912
  • Fax: 320-763-6629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number303756
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: