Healthcare Provider Details

I. General information

NPI: 1962476655
Provider Name (Legal Business Name): PAULA J PITTERLE PHD LP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CHICAGO AVE SOUTH CHILDRENS SPECIALTY CLINIC - PSYCHOLOGICAL SERVICES
MINNEAPOLIS MN
55404
US

IV. Provider business mailing address

2910 CENTRE POINTE DR 35-121A CHILDRENS HEALTH CARE
ROSEVILLE MN
55113
US

V. Phone/Fax

Practice location:
  • Phone: 612-813-8455
  • Fax: 612-813-8263
Mailing address:
  • Phone: 651-855-2109
  • Fax: 651-855-2310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberLP4646
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: