Provider Demographics
NPI:1356404503
Name:PETZEL, SUE V (PHD)
Entity type:Individual
Prefix:DR
First Name:SUE
Middle Name:V
Last Name:PETZEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - Street 2:420 DELAWARE ST SE, MMC 395
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-5545
Mailing Address - Country:US
Mailing Address - Phone:612-273-7111
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - Street 2:606 24TH AVE S, SUITE 300
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-5545
Practice Address - Country:US
Practice Address - Phone:612-273-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1118103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1014714OtherPREFERREDONE
HP28968OtherHP28968
61-32171OtherMEDICA PRIMARY
00T05PEOtherBLUE CROSS BLUE SHIELD
102819OtherUCARE
61-32171OtherMEDICA CHOICE
WI39125900Medicaid
768304OtherARAZ
768304OtherARAZ