Provider Demographics
NPI:1437106770
Name:GRUNZKE-LYNNER, NICOLE PAIGE (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:PAIGE
Last Name:GRUNZKE-LYNNER
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8855 RIVER HEIGHTS WAY
Mailing Address - Street 2:
Mailing Address - City:INVER GROVE HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55076-3479
Mailing Address - Country:US
Mailing Address - Phone:651-554-9407
Mailing Address - Fax:
Practice Address - Street 1:2388 UNIVERSITY AVE W
Practice Address - Street 2:#207
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1769
Practice Address - Country:US
Practice Address - Phone:952-210-1360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4347103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN557344100OtherMEDICAL ASSISTANCE
MN156M3GROtherBCBS
MN6142042OtherSTATE TAX ID
MN61-42042OtherUBH
MN6142042OtherSTATE TAX ID