Healthcare Provider Details

I. General information

NPI: 1952165615
Provider Name (Legal Business Name): KAYLEIGH GWEN GRONSETH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAYLEIGH COSDEN

II. Dates (important events)

Enumeration Date: 02/12/2024
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22018 S CENTRAL POINT RD
CANBY OR
97013-8705
US

IV. Provider business mailing address

3155 S MOODY AVE APT 313
PORTLAND OR
97239-4731
US

V. Phone/Fax

Practice location:
  • Phone: 503-221-4531
  • Fax: 866-485-6741
Mailing address:
  • Phone: 224-623-7434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: