Provider Demographics
NPI:1154503076
Name:PETERSON, BETH K (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:K
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7365 KIRKWOOD CT.
Mailing Address - Street 2:SUITE 360
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369
Mailing Address - Country:US
Mailing Address - Phone:763-424-9591
Mailing Address - Fax:763-496-0635
Practice Address - Street 1:7365 KIRKWOOD CT.
Practice Address - Street 2:SUITE 360
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369
Practice Address - Country:US
Practice Address - Phone:763-424-9591
Practice Address - Fax:763-496-0635
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN159751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical