Provider Demographics
NPI:1376739656
Name:PETERSON, GLORIA DEAN SCALES (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:DEAN SCALES
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 22305
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-9998
Mailing Address - Country:US
Mailing Address - Phone:612-239-7119
Mailing Address - Fax:612-632-8653
Practice Address - Street 1:3333 NORTH 4TH STREET
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55412
Practice Address - Country:US
Practice Address - Phone:612-239-7119
Practice Address - Fax:612-632-8653
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN36961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6220443Medicaid
MN04931550OtherMEDICAL ASSISTANCE