Provider Demographics
NPI:1376856518
Name:BOEHM-PETERSON, CORI CHRISTINA (LICSW)
Entity Type:Individual
Prefix:
First Name:CORI
Middle Name:CHRISTINA
Last Name:BOEHM-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 1:701 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1623
Mailing Address - Country:US
Mailing Address - Phone:612-873-3000
Mailing Address - Fax:
Practice Address - Street 1:701 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1623
Practice Address - Country:US
Practice Address - Phone:612-873-4304
Practice Address - Fax:612-904-4304
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN142961041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool