Provider Demographics
NPI:1962506493
Name:PENTICOFF, RENEE MARIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:RENEE
Middle Name:MARIE
Last Name:PENTICOFF
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25334
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-0334
Mailing Address - Country:US
Mailing Address - Phone:651-255-6678
Mailing Address - Fax:651-501-6091
Practice Address - Street 1:1818 WOODDALE DR
Practice Address - Street 2:SUITE 204
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2940
Practice Address - Country:US
Practice Address - Phone:651-255-6678
Practice Address - Fax:651-501-6091
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 4060103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical