Provider Demographics
NPI:1073532230
Name:ZITZOW, DARRYL ROBERT (PHD)
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:ROBERT
Last Name:ZITZOW
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29353 NO SUGARBUSH ROAD
Mailing Address - Street 2:
Mailing Address - City:OGEMA
Mailing Address - State:MN
Mailing Address - Zip Code:56569
Mailing Address - Country:US
Mailing Address - Phone:218-983-3299
Mailing Address - Fax:
Practice Address - Street 1:40520 CO HWY 34
Practice Address - Street 2:WHITE EARTH HEALTH CENTER
Practice Address - City:OGEMA
Practice Address - State:MN
Practice Address - Zip Code:56569
Practice Address - Country:US
Practice Address - Phone:218-983-4300
Practice Address - Fax:218-983-6217
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4562103T00000X
MN7173104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6157953OtherMEDICA
MN03T99ZIOtherBCBS
MN585241045032OtherPREFERRED ONE
8HZ786Medicare ID - Type Unspecified