Provider Demographics
NPI:1396843413
Name:PEDERSON, CORTNEY (MSW LICSW)
Entity Type:Individual
Prefix:
First Name:CORTNEY
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:CORTNEY
Other - Middle Name:LYNN
Other - Last Name:SIDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW LICSW
Mailing Address - Street 1:6600 FRANCE AVE S
Mailing Address - Street 2:STE 230
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1805
Mailing Address - Country:US
Mailing Address - Phone:952-835-2002
Mailing Address - Fax:952-835-9889
Practice Address - Street 1:6600 FRANCE AVE S
Practice Address - Street 2:STE 320
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1805
Practice Address - Country:US
Practice Address - Phone:952-835-2002
Practice Address - Fax:952-835-9889
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15940103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4045202OtherUCARE
MN4045202OtherBHP
MN954694400Medicaid
MN199P1STOtherBCBS
MNHP49679OtherHEALTH PARTNERS
MN954694400Medicaid