Provider Demographics
NPI:1215097928
Name:KIRVIDA, GRETCHEN SUZANNE (LICSW)
Entity type:Individual
Prefix:MRS
First Name:GRETCHEN
Middle Name:SUZANNE
Last Name:KIRVIDA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:CENTER CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55012
Mailing Address - Country:US
Mailing Address - Phone:651-257-5399
Mailing Address - Fax:
Practice Address - Street 1:7039 20TH AVE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:MN
Practice Address - Zip Code:55038-9737
Practice Address - Country:US
Practice Address - Phone:651-288-0332
Practice Address - Fax:651-288-0493
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN169876OtherUCARE
MN205M6KIOtherBC BS
MN4028602OtherBHP
MN17395900Medicaid
MNHP37279OtherHEALTH PARTNERS