Provider Demographics
NPI:1558596122
Name:GRUCHOW, KRISTABELLE MARIA (OTR)
Entity Type:Individual
Prefix:
First Name:KRISTABELLE
Middle Name:MARIA
Last Name:GRUCHOW
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 PENNSYLVANIA AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-2507
Mailing Address - Country:US
Mailing Address - Phone:586-292-7064
Mailing Address - Fax:
Practice Address - Street 1:3931 LOUISANA AVE S
Practice Address - Street 2:E400
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426
Practice Address - Country:US
Practice Address - Phone:586-292-7064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-26
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004889225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist