Provider Demographics
NPI:1972923373
Name:GRONNEBERG, CIA
Entity type:Individual
Prefix:
First Name:CIA
Middle Name:
Last Name:GRONNEBERG
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:BOX 567
Mailing Address - Street 2:912 BURREL AVE SE
Mailing Address - City:COOPERSTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58425-0567
Mailing Address - Country:US
Mailing Address - Phone:701-797-2127
Mailing Address - Fax:701-797-2172
Practice Address - Street 1:912 BURREL AVE SE
Practice Address - Street 2:BOX 567
Practice Address - City:COOPERSTOWN
Practice Address - State:ND
Practice Address - Zip Code:58425-0567
Practice Address - Country:US
Practice Address - Phone:701-797-2127
Practice Address - Fax:701-797-2172
Is Sole Proprietor?:No
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3023104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker