Provider Demographics
NPI:1326439605
Name:PETRACCA SELK, ARIEL (LAC, DACM)
Entity Type:Individual
Prefix:DR
First Name:ARIEL
Middle Name:
Last Name:PETRACCA SELK
Suffix:
Gender:F
Credentials:LAC, DACM
Other - Prefix:
Other - First Name:ARIEL
Other - Middle Name:
Other - Last Name:PETRACCA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:1608 WATERLOO AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55075-1050
Mailing Address - Country:US
Mailing Address - Phone:808-321-5337
Mailing Address - Fax:
Practice Address - Street 1:14585 GRAND AVE
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-5719
Practice Address - Country:US
Practice Address - Phone:952-435-7349
Practice Address - Fax:951-417-6159
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1602171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist