Healthcare Provider Details

I. General information

NPI: 1548806839
Provider Name (Legal Business Name): KORI JILL GUZA LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 5TH AVE
WORTHINGTON MN
56187-2432
US

IV. Provider business mailing address

PO BOX 175
WORTHINGTON MN
56187-0175
US

V. Phone/Fax

Practice location:
  • Phone: 507-376-4141
  • Fax: 507-376-4494
Mailing address:
  • Phone: 507-376-4141
  • Fax: 507-376-4494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC02287
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: