Provider Demographics
NPI:1518688720
Name:BETHANY PETERSON, PLLC
Entity Type:Organization
Organization Name:BETHANY PETERSON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:BETHANY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LICSW, LAC
Authorized Official - Phone:218-329-9345
Mailing Address - Street 1:110 15TH ST SE
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56514-3315
Mailing Address - Country:US
Mailing Address - Phone:218-329-9345
Mailing Address - Fax:
Practice Address - Street 1:3523 45TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8962
Practice Address - Country:US
Practice Address - Phone:218-329-9345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty