Provider Demographics
NPI:1639178049
Name:GRONNEBERG, PAUL (MA, LP)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:GRONNEBERG
Suffix:
Gender:M
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 S FRONT ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-3803
Mailing Address - Country:US
Mailing Address - Phone:507-387-3777
Mailing Address - Fax:507-344-1726
Practice Address - Street 1:730 S FRONT ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3803
Practice Address - Country:US
Practice Address - Phone:507-387-3777
Practice Address - Fax:507-344-1726
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0728103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN115278OtherUCARE
MN6162711OtherUNITED BEHAVIORAL HEALTH
MN33P34GROtherBLUE CROSS BLUE SHIELD