Basic Information
| Provider Information | |||||||||
| NPI: | 1972871275 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORACKE | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7066 STILLWATER BLVD N | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551283937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512957474 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4133 IOWA ST | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563083316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207628851 | ||||||||
| FaxNumber: | 6519250057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2011 | ||||||||
| LastUpdateDate: | 06/21/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 2540 | MN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.