Healthcare Provider Details

I. General information

NPI: 1376649020
Provider Name (Legal Business Name): DELORES A DINZEO LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 E HIGHWAY 96 SUITE 200
WHITE BEAR LAKE MN
55110-3483
US

IV. Provider business mailing address

1772 SKILLMAN AVE W
ROSEVILLE MN
55113-5620
US

V. Phone/Fax

Practice location:
  • Phone: 651-426-3071
  • Fax: 651-426-3095
Mailing address:
  • Phone: 651-647-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3582
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: