Provider Demographics
NPI:1346792256
Name:PETERSON, DONNA (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:DONNA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:RAY
Mailing Address - State:ND
Mailing Address - Zip Code:58849-0096
Mailing Address - Country:US
Mailing Address - Phone:701-568-3385
Mailing Address - Fax:
Practice Address - Street 1:1500 14TH ST SW
Practice Address - Street 2:SUITE 250
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801
Practice Address - Country:US
Practice Address - Phone:701-334-6242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND53391041C0700X
NY0823441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical