Basic Information
| Provider Information | |||||||||
| NPI: | 1528263704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEZOA | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, LPCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PEZOA | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | D. | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW, LPCC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3033 CAMPUS DR STE W2253033 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554412651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009976196 | ||||||||
| FaxNumber: | 8335239924 | ||||||||
| Practice Location | |||||||||
| Address1: | 3033 CAMPUS DR STE W225 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554412752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009976196 | ||||||||
| FaxNumber: | 8335239924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPCC817 | CA | N | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | LCSW22323 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.