| Doctor Name: | MR. GEORGE LORNE TETREAULT |
| NPI Number: | 1306940333 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | LP2766 |
| Business Practice Address: | 11614 Rivervista Dr Baxter, MN - 564257605 |
| Business Phone Number: | 2188290905 |
| Business Fax Number: | 2188290905 |
| Mailing Address: | 11614 Rivervista Dr, BAXTER |
| State: | MN |
| Postal Code: | 564257605 |
| Phone Number: | 2188290905 |
| Fax Number: | 2188290905 |
| NPI Enumeration Date: | 09/11/2006 |
| NPI Last Update Date: | 11/18/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | LP2766 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MN |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |