Provider Demographics
NPI:1346269032
Name:PETERSON, DONNA SUE (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:SUE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:SUE
Other - Last Name:DAIKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD, LP
Mailing Address - Street 1:PO BOX 1050
Mailing Address - Street 2:
Mailing Address - City:CROSSLAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56442-1050
Mailing Address - Country:US
Mailing Address - Phone:763-226-1954
Mailing Address - Fax:
Practice Address - Street 1:13045 FALCON DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-4201
Practice Address - Country:US
Practice Address - Phone:218-829-9307
Practice Address - Fax:218-829-7649
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2983103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN938055800Medicaid