Provider Demographics
NPI:1972871275
Name:GORACKE, KRISTIN K (MA)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:K
Last Name:GORACKE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7066 STILLWATER BLVD N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55128-3937
Mailing Address - Country:US
Mailing Address - Phone:651-295-7474
Mailing Address - Fax:
Practice Address - Street 1:4133 IOWA ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3316
Practice Address - Country:US
Practice Address - Phone:320-762-8851
Practice Address - Fax:651-925-0057
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2540106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist