Healthcare Provider Details

I. General information

NPI: 1316954985
Provider Name (Legal Business Name): KARY J GILLENWATERS OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KARY REULE LAC

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15590 90TH ST NE
OTSEGO MN
55330-9452
US

IV. Provider business mailing address

15590 90TH ST NE
OTSEGO MN
55330-9452
US

V. Phone/Fax

Practice location:
  • Phone: 763-755-4275
  • Fax:
Mailing address:
  • Phone: 763-755-4275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1458
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: