Provider Demographics
NPI:1386648327
Name:KRUPP, GARY J (PHD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:J
Last Name:KRUPP
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 CHICAGO AVE SOUTH
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1320
Mailing Address - Country:US
Mailing Address - Phone:612-879-1000
Mailing Address - Fax:612-879-9116
Practice Address - Street 1:2828 CHICAGO AVE SOUTH
Practice Address - Street 2:SUITE 200
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1320
Practice Address - Country:US
Practice Address - Phone:612-879-1000
Practice Address - Fax:612-879-9116
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0167103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6800000064Medicaid
MN408848400Medicare ID - Type Unspecified