Provider Demographics
NPI:1598861056
Name:PEDERSON, COLLEEN MARIE (LMFT)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:MARIE
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7801
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-7801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:513 5TH ST SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3216
Practice Address - Country:US
Practice Address - Phone:320-214-0098
Practice Address - Fax:320-214-9924
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2009-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1324106H00000X
MNR 08429-9163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health