Provider Demographics
NPI:1669435368
Name:ZAUDTKE, MARY SUE (MA LP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:SUE
Last Name:ZAUDTKE
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 1:1250 MOORE LAKE DR E STE 220
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-5135
Mailing Address - Country:US
Mailing Address - Phone:952-388-8990
Mailing Address - Fax:
Practice Address - Street 1:1250 MOORE LAKE DR E STE 220
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-5135
Practice Address - Country:US
Practice Address - Phone:952-388-8990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3667103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist