Provider Demographics
NPI:1154178242
Name:PRENZLOW, ELLIE MARGARET
Entity type:Individual
Prefix:
First Name:ELLIE
Middle Name:MARGARET
Last Name:PRENZLOW
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 1:610 JESSAMINE AVE E APT 2
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55130-3745
Mailing Address - Country:US
Mailing Address - Phone:612-220-0523
Mailing Address - Fax:
Practice Address - Street 1:731 BIELENBERG DR STE 102-104
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1700
Practice Address - Country:US
Practice Address - Phone:602-820-7679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician