Healthcare Provider Details

I. General information

NPI: 1568765881
Provider Name (Legal Business Name): PEGGYE MEZILE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 HIGHWAY 36 W SUITE 450
ROSEVILLE MN
55113-4034
US

IV. Provider business mailing address

1700 HIGHWAY 36 W SUITE 450
ROSEVILLE MN
55113-4034
US

V. Phone/Fax

Practice location:
  • Phone: 651-659-0460
  • Fax: 651-644-5306
Mailing address:
  • Phone: 651-659-0460
  • Fax: 651-644-5306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11599
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: