Provider Demographics
NPI:1952150567
Name:KRISHNAN, GAUTHAM
Entity type:Individual
Prefix:
First Name:GAUTHAM
Middle Name:
Last Name:KRISHNAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6390 DOUGLAS DR N APT 204
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55429-1980
Mailing Address - Country:US
Mailing Address - Phone:612-900-9385
Mailing Address - Fax:
Practice Address - Street 1:7400 METRO BLVD STE 227
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2470
Practice Address - Country:US
Practice Address - Phone:612-712-5244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health