Provider Demographics
NPI:1053685487
Name:TETZLAFF, DANIEL TIMOTHY (PSYD, JD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:TIMOTHY
Last Name:TETZLAFF
Suffix:
Gender:M
Credentials:PSYD, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 E 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-3111
Mailing Address - Country:US
Mailing Address - Phone:906-635-7270
Mailing Address - Fax:
Practice Address - Street 1:605 E 7TH AVE
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-3111
Practice Address - Country:US
Practice Address - Phone:906-635-7270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015059103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical