Provider Demographics
NPI:1912050584
Name:GORRELL, KATHERINE P
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:P
Last Name:GORRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 TREJO STREET
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440
Mailing Address - Country:US
Mailing Address - Phone:208-356-3776
Mailing Address - Fax:208-356-9498
Practice Address - Street 1:1600 JOHN ADAMS PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4300
Practice Address - Country:US
Practice Address - Phone:208-529-5276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID276031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical