Provider Demographics
NPI:1780785980
Name:ZELLER, SIMON (LICSW)
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:ZELLER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 FARIBAULT RD
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-5780
Mailing Address - Country:US
Mailing Address - Phone:507-334-1983
Mailing Address - Fax:507-333-2307
Practice Address - Street 1:1400 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912
Practice Address - Country:US
Practice Address - Phone:507-437-9152
Practice Address - Fax:507-437-9187
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN01124101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01124OtherLICENSE NUMBER