Provider Demographics
NPI:1568765881
Name:MEZILE, PEGGYE
Entity Type:Individual
Prefix:
First Name:PEGGYE
Middle Name:
Last Name:MEZILE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 HIGHWAY 36 W
Mailing Address - Street 2:SUITE 450
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4034
Mailing Address - Country:US
Mailing Address - Phone:651-659-0460
Mailing Address - Fax:651-644-5306
Practice Address - Street 1:1700 HIGHWAY 36 W
Practice Address - Street 2:SUITE 450
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4034
Practice Address - Country:US
Practice Address - Phone:651-659-0460
Practice Address - Fax:651-644-5306
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical