Provider Demographics
NPI:1598342503
Name:PETERSON, ERIC (MA, LADC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MA, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2734 DELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1825
Mailing Address - Country:US
Mailing Address - Phone:218-393-6744
Mailing Address - Fax:
Practice Address - Street 1:1611 COUNTY ROAD B W STE 214
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4053
Practice Address - Country:US
Practice Address - Phone:612-412-4873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305906101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)