Provider Demographics
NPI:1699072793
Name:PETZOLD, BERNAQDINE ANN
Entity type:Individual
Prefix:DR
First Name:BERNAQDINE
Middle Name:ANN
Last Name:PETZOLD
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 1:524 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2847
Mailing Address - Country:US
Mailing Address - Phone:248-765-5735
Mailing Address - Fax:
Practice Address - Street 1:524 E 4TH ST
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-2847
Practice Address - Country:US
Practice Address - Phone:800-963-9163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401005086103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist