Provider Demographics
NPI:1114470663
Name:MCCOURTNEY GREDVIG, ROCHELLE ELIZABETH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROCHELLE
Middle Name:ELIZABETH
Last Name:MCCOURTNEY GREDVIG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4913 KALENDA AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55301-4613
Mailing Address - Country:US
Mailing Address - Phone:763-464-3064
Mailing Address - Fax:
Practice Address - Street 1:13603 80TH CIR N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-8961
Practice Address - Country:US
Practice Address - Phone:763-274-3120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling