Provider Demographics
NPI:1770812174
Name:GRUDZINSKI, HEATHER LYNN HANSON (LPC)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:LYNN HANSON
Last Name:GRUDZINSKI
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:LYNN
Other - Last Name:HANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7400 METRO BLVD #100-6
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439
Mailing Address - Country:US
Mailing Address - Phone:612-564-0251
Mailing Address - Fax:612-253-0502
Practice Address - Street 1:7400 METRO BLVD #100-6
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439
Practice Address - Country:US
Practice Address - Phone:612-564-0251
Practice Address - Fax:612-253-0502
Is Sole Proprietor?:No
Enumeration Date:2009-12-14
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC02413101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO494461106Medicaid