Healthcare Provider Details

I. General information

NPI: 1366170417
Provider Name (Legal Business Name): DANIELLE PETRUSKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7066 STILLWATER BLVD N
OAKDALE MN
55128-3937
US

IV. Provider business mailing address

5521 NOKOMIS AVE
MINNEAPOLIS MN
55417-2024
US

V. Phone/Fax

Practice location:
  • Phone: 651-777-5222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP7382
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: