Provider Demographics
NPI:1134199805
Name:GROSE, KATHLEEN G (MA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:G
Last Name:GROSE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:BRETCHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4820 SW LEAFWING DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64082-4865
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 GALAXIE AVE
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-2084
Practice Address - Country:US
Practice Address - Phone:816-380-5167
Practice Address - Fax:816-380-5841
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003030538101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499305001Medicaid