Provider Demographics
NPI:1306085329
Name:GRYNICK, KIM LUDMILA
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:LUDMILA
Last Name:GRYNICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:LUDMILA
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:1257 SISKIYOU BLVD
Mailing Address - Street 2:#194
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-2241
Mailing Address - Country:US
Mailing Address - Phone:541-517-4715
Mailing Address - Fax:
Practice Address - Street 1:737 SISKIYOU BLVD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2141
Practice Address - Country:US
Practice Address - Phone:541-517-4715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-14
Last Update Date:2009-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1749101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional