Provider Demographics
NPI:1053307025
Name:PETERSON, SANDRA LUANN (LICSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LUANN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21078 115TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-9313
Mailing Address - Country:US
Mailing Address - Phone:218-681-3658
Mailing Address - Fax:
Practice Address - Street 1:120 LABREE AVE S
Practice Address - Street 2:NORTHWEST MEDICAL CENTER
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-2819
Practice Address - Country:US
Practice Address - Phone:218-681-4240
Practice Address - Fax:218-681-5614
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN48471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN09493300Medicaid
MN336L2PEOtherBCBS