Provider Demographics
NPI:1487865549
Name:NIEDERLOH, POLLY SUSAN (LP)
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:SUSAN
Last Name:NIEDERLOH
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 JERSEY AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-2237
Mailing Address - Country:US
Mailing Address - Phone:952-593-5484
Mailing Address - Fax:
Practice Address - Street 1:1330 JERSEY AVE S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-2237
Practice Address - Country:US
Practice Address - Phone:952-593-5484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3130103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist