Basic Information
| Provider Information | |||||||||
| NPI: | 1538560370 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORHAM | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | KERSTIN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GORHAM | ||||||||
| OtherFirstName: | ANNE | ||||||||
| OtherMiddleName: | KERSTIN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMFT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3450 OLEARY LN | ||||||||
| Address2: | |||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551232340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513658238 | ||||||||
| FaxNumber: | 6514543492 | ||||||||
| Practice Location | |||||||||
| Address1: | 3450 OLEARY LN | ||||||||
| Address2: | |||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551232340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513658238 | ||||||||
| FaxNumber: | 6514543492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2014 | ||||||||
| LastUpdateDate: | 12/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 3096 | MN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.