Healthcare Provider Details

I. General information

NPI: 1598895591
Provider Name (Legal Business Name): LINDA PETSOULIS M.A., L.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 W SUPERIOR ST SUITE 600
DULUTH MN
55802-1805
US

IV. Provider business mailing address

314 W SUPERIOR ST SUITE 600
DULUTH MN
55802-1805
US

V. Phone/Fax

Practice location:
  • Phone: 218-727-7353
  • Fax: 218-727-2646
Mailing address:
  • Phone: 218-727-7353
  • Fax: 218-727-2646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP3664
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: