Provider Demographics
NPI:1265849780
Name:PETERSEN, NERGIS (MA, LPCC)
Entity Type:Individual
Prefix:
First Name:NERGIS
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 DECATUR AVE N STE 109
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4363
Mailing Address - Country:US
Mailing Address - Phone:763-746-2400
Mailing Address - Fax:763-746-2401
Practice Address - Street 1:701 DECATUR AVE N STE 109
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4363
Practice Address - Country:US
Practice Address - Phone:763-746-2400
Practice Address - Fax:763-746-2401
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00807101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional