Healthcare Provider Details

I. General information

NPI: 1700190808
Provider Name (Legal Business Name): MARY KATHLEEN GOSSE M.A., REV.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2010
Last Update Date: 07/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 LYNDALE AVE S SUITE 191
BLOOMINGTON MN
55420-5614
US

IV. Provider business mailing address

16099 NORTHWOOD RD NW
PRIOR LAKE MN
55372-1612
US

V. Phone/Fax

Practice location:
  • Phone: 952-884-5803
  • Fax:
Mailing address:
  • Phone: 952-212-1756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: