Provider Demographics
NPI:1619441995
Name:FAILLETTAZ, PIERRE HENRI (BA, MDIV, LADC)
Entity Type:Individual
Prefix:
First Name:PIERRE
Middle Name:HENRI
Last Name:FAILLETTAZ
Suffix:
Gender:M
Credentials:BA, MDIV, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3409 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-2023
Mailing Address - Country:US
Mailing Address - Phone:612-999-8215
Mailing Address - Fax:651-393-5161
Practice Address - Street 1:3409 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-2023
Practice Address - Country:US
Practice Address - Phone:612-999-8215
Practice Address - Fax:651-393-5161
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-19
Last Update Date:2019-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304389101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty