MEDICARE: DR. PETER ANDREW ZELLES PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	LP1383	MN
2	103TC0700X	Clinical Psychologist	1673	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265438022
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER ANDREW ZELLES PH.D.

Provider Business Mailing Address
First Line	:	235 FAIRVIEW AVE S
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1551
Country	:	US
Telephone Number	:	651-698-8745
Fax Number	:

Provider Business Practice Location Address
First Line	:	235 FAIRVIEW AVE S
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1551
Country	:	US
Telephone Number	:	651-698-8745
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	09/11/2009

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