Provider Demographics
NPI:1003978024
Name:PETZ, DIANE V (MS, LP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:V
Last Name:PETZ
Suffix:
Gender:F
Credentials:MS, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 E 3RD ST
Mailing Address - Street 2:201
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-3478
Mailing Address - Country:US
Mailing Address - Phone:507-452-7292
Mailing Address - Fax:507-457-9887
Practice Address - Street 1:66 E 3RD ST
Practice Address - Street 2:201
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-3478
Practice Address - Country:US
Practice Address - Phone:507-452-7292
Practice Address - Fax:507-457-9887
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3132103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN731291024499OtherPREFERRED ONE
MN118043Medicaid
MN975T0PEOtherBCBS-MN
MNHP29923OtherHEALTHPARTNERS