Provider Demographics
NPI:1669217113
Name:PETRICH, DENISE J
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:J
Last Name:PETRICH
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 1:3673 LEXINGTON AVE N STE H-2101
Mailing Address - Street 2:
Mailing Address - City:ARDEN HILLS
Mailing Address - State:MN
Mailing Address - Zip Code:55126-2984
Mailing Address - Country:US
Mailing Address - Phone:651-485-4380
Mailing Address - Fax:
Practice Address - Street 1:1818 WOODDALE DR STE 110
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2947
Practice Address - Country:US
Practice Address - Phone:651-485-4380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN233591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical