Provider Demographics
NPI:1417175571
Name:ERSTAD, DUANE HENRY (PHD)
Entity Type:Individual
Prefix:DR
First Name:DUANE
Middle Name:HENRY
Last Name:ERSTAD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:DUANE
Other - Middle Name:
Other - Last Name:ERSTAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1233 19TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-4317
Mailing Address - Country:US
Mailing Address - Phone:414-550-4515
Mailing Address - Fax:
Practice Address - Street 1:CARRERA 13, NO. 85-39
Practice Address - Street 2:SUITE 608
Practice Address - City:BOGOTA
Practice Address - State:DC
Practice Address - Zip Code:00000
Practice Address - Country:CO
Practice Address - Phone:414-550-4515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2094103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42149800Medicaid
WI084452006Medicare ID - Type UnspecifiedPSYCHOLOGIST