Provider Demographics
NPI:1033544119
Name:PETERSON, MICHAEL ROBERT (LMFT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 SAINT CROIX TRL N APT 119
Mailing Address - Street 2:
Mailing Address - City:OAK PARK HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6966
Mailing Address - Country:US
Mailing Address - Phone:612-220-6038
Mailing Address - Fax:
Practice Address - Street 1:522 4TH ST S
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-4966
Practice Address - Country:US
Practice Address - Phone:612-220-6038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-09
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1565101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health