Provider Demographics
NPI:1588794598
Name:PETSOULIS, CHRISTOS NAPOLEON (MA, LP)
Entity type:Individual
Prefix:
First Name:CHRISTOS
Middle Name:NAPOLEON
Last Name:PETSOULIS
Suffix:
Gender:M
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 1:314 W SUPERIOR ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1805
Mailing Address - Country:US
Mailing Address - Phone:218-727-7353
Mailing Address - Fax:218-727-2646
Practice Address - Street 1:314 W SUPERIOR ST
Practice Address - Street 2:SUITE 600
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1805
Practice Address - Country:US
Practice Address - Phone:218-727-7353
Practice Address - Fax:218-727-2646
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3014103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN105522OtherUCARE MN
MN30A54PEOtherBLUE CROSS BLUE SHIELD