Provider Demographics
NPI:1538124532
Name:PETERSON, BONNIE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:
Other - Last Name:RICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:1451 44TH AVE S
Mailing Address - Street 2:PO BOX 14545
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3434
Mailing Address - Country:US
Mailing Address - Phone:701-775-2500
Mailing Address - Fax:701-787-8996
Practice Address - Street 1:1451 44TH AVE S
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3434
Practice Address - Country:US
Practice Address - Phone:701-775-2500
Practice Address - Fax:701-787-8996
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND20241041C0700X
MN116201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN562323500Medicaid
ND14785OtherND BC/BS
MN02T25RIOtherMN BC/BS
ND14785Medicare ID - Type Unspecified