Provider Demographics
NPI:1073987947
Name:PETERSON COUNSELING AND CONSULTING LLC
Entity Type:Organization
Organization Name:PETERSON COUNSELING AND CONSULTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RACHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS LPC LADC CCTP
Authorized Official - Phone:608-332-3490
Mailing Address - Street 1:2442 LACY LN
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:MN
Mailing Address - Zip Code:55386-2302
Mailing Address - Country:US
Mailing Address - Phone:608-332-3490
Mailing Address - Fax:
Practice Address - Street 1:10650 COUNTY ROAD 81 STE 205
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4040
Practice Address - Country:US
Practice Address - Phone:608-332-3490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304016101YA0400X
MN01688101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty