Provider Demographics
NPI:1700190808
Name:GOSSE, MARY KATHLEEN (MA, REV)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHLEEN
Last Name:GOSSE
Suffix:
Gender:F
Credentials:MA, REV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16099 NORTHWOOD RD NW
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-1612
Mailing Address - Country:US
Mailing Address - Phone:952-212-1756
Mailing Address - Fax:
Practice Address - Street 1:10800 LYNDALE AVE S
Practice Address - Street 2:SUITE 191
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-5614
Practice Address - Country:US
Practice Address - Phone:952-884-5803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral