Provider Demographics
NPI:1255362281
Name:GROSKREUTZ, MELISSA JO (LP)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:JO
Last Name:GROSKREUTZ
Suffix:
Gender:F
Credentials:LP
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:JO
Other - Last Name:GLACKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3756 210TH AVE
Mailing Address - Street 2:
Mailing Address - City:WELLS
Mailing Address - State:MN
Mailing Address - Zip Code:56097-3205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:342 BELGRADE AVE
Practice Address - Street 2:
Practice Address - City:NORTH MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56003-3804
Practice Address - Country:US
Practice Address - Phone:507-388-3181
Practice Address - Fax:507-388-3199
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4018103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN620220900Medicaid