Healthcare Provider Details

I. General information

NPI: 1982621926
Provider Name (Legal Business Name): GRETCHEN E WEATHERLY PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 01/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 UNIVERSITY AVE E CHILD AND FAMILY SERVICES DEPARTMENT
SAINT PAUL MN
55101-2507
US

IV. Provider business mailing address

200 UNIVERSITY AVE E GILLETTE CHILDRENS SPECIALTY HEALTHCARE
SAINT PAUL MN
55101
US

V. Phone/Fax

Practice location:
  • Phone: 651-229-3855
  • Fax: 651-602-6891
Mailing address:
  • Phone: 651-229-3855
  • Fax: 651-602-6891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberLP4427
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: