Healthcare Provider Details

I. General information

NPI: 1396569166
Provider Name (Legal Business Name): BETH KINYUA-GATHETU LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2024
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 HIGHWAY 12 E STE 2
WILLMAR MN
56201-5811
US

IV. Provider business mailing address

2320 HIGHWAY 12 E STE 2
WILLMAR MN
56201-5811
US

V. Phone/Fax

Practice location:
  • Phone: 320-214-9692
  • Fax: 320-214-9924
Mailing address:
  • Phone: 320-214-9692
  • Fax: 320-214-9924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4666
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: