Provider Demographics
NPI:1891823373
Name:RETTERATH, PAMELA LOUISE (MA,LP)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:LOUISE
Last Name:RETTERATH
Suffix:
Gender:F
Credentials:MA,LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54135 244TH ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-5636
Mailing Address - Country:US
Mailing Address - Phone:507-433-4715
Mailing Address - Fax:507-433-7868
Practice Address - Street 1:54135 244TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-5636
Practice Address - Country:US
Practice Address - Phone:507-433-4715
Practice Address - Fax:507-433-7868
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP # 3552103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent