Provider Demographics
NPI:1366491466
Name:PETERMANN, JOY MARIE (MSW LICSW)
Entity Type:Individual
Prefix:MS
First Name:JOY
Middle Name:MARIE
Last Name:PETERMANN
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 1:5353 WAYZATA BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1316
Mailing Address - Country:US
Mailing Address - Phone:763-432-4072
Mailing Address - Fax:763-432-4073
Practice Address - Street 1:5353 WAYZATA BLVD STE 202
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1316
Practice Address - Country:US
Practice Address - Phone:763-432-4072
Practice Address - Fax:763-432-4073
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN149681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
712687500OtherCADI