Provider Demographics
NPI:1285166355
Name:GUBRUD, ROSS E (PHD)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:E
Last Name:GUBRUD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 XENIUM LN N APT 123
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2222
Mailing Address - Country:US
Mailing Address - Phone:612-421-3178
Mailing Address - Fax:612-421-3183
Practice Address - Street 1:1821 UNIVERSITY AVE W STE 461-9
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-2801
Practice Address - Country:US
Practice Address - Phone:612-421-3178
Practice Address - Fax:612-421-3183
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5984103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical