Provider Demographics
NPI:1245061803
Name:GRONWOLD, BROOKE (MS)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:GRONWOLD
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-8753
Mailing Address - Country:US
Mailing Address - Phone:701-451-4900
Mailing Address - Fax:
Practice Address - Street 1:2823 30TH ST S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5454
Practice Address - Country:US
Practice Address - Phone:218-329-7638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional