Provider Demographics
NPI:1982621926
Name:WEATHERLY, GRETCHEN E (PHD)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:E
Last Name:WEATHERLY
Suffix:
Gender:F
Credentials:PHD
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Mailing Address - Street 1:200 UNIVERSITY AVE E
Mailing Address - Street 2:GILLETTE CHILDRENS SPECIALTY HEALTHCARE
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101
Mailing Address - Country:US
Mailing Address - Phone:651-229-3855
Mailing Address - Fax:651-602-6891
Practice Address - Street 1:200 UNIVERSITY AVE E
Practice Address - Street 2:CHILD AND FAMILY SERVICES DEPARTMENT
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2507
Practice Address - Country:US
Practice Address - Phone:651-229-3855
Practice Address - Fax:651-602-6891
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNLP4427103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist