Healthcare Provider Details

I. General information

NPI: 1356404503
Provider Name (Legal Business Name): SUE V PETZEL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF MINNESOTA PHYSICIANS 606 24TH AVE S, SUITE 300
MINNEAPOLIS MN
55455-5545
US

IV. Provider business mailing address

UNIVERSITY OF MINNESOTA PHYSICIANS 420 DELAWARE ST SE, MMC 395
MINNEAPOLIS MN
55455-5545
US

V. Phone/Fax

Practice location:
  • Phone: 612-273-7111
  • Fax:
Mailing address:
  • Phone: 612-273-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP1118
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: