Healthcare Provider Details

I. General information

NPI: 1609308014
Provider Name (Legal Business Name): KATHY GRUIS MA, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 5TH AVE
WORTHINGTON MN
56187-2432
US

IV. Provider business mailing address

1210 5TH AVE
WORTHINGTON MN
56187-2432
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 Code101YP2500X
TaxonomyProfessional Counselor
License Number1501
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: