Provider Demographics
NPI:1881805125
Name:GROTHE-BUMGARDNER, TONYA ANNE (MS)
Entity type:Individual
Prefix:MRS
First Name:TONYA
Middle Name:ANNE
Last Name:GROTHE-BUMGARDNER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 3RD ST NW
Mailing Address - Street 2:PO BOX 92
Mailing Address - City:FULDA
Mailing Address - State:MN
Mailing Address - Zip Code:56131-1108
Mailing Address - Country:US
Mailing Address - Phone:507-380-8806
Mailing Address - Fax:
Practice Address - Street 1:1024 7TH AVE
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-2287
Practice Address - Country:US
Practice Address - Phone:507-376-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00122101YM0800X
MN1410106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN931613000Medicaid