Provider Demographics
NPI:1619495108
Name:PETERSEN, REBECCA MARIE (LAC)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:MARIE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 PILGRIM LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-3256
Mailing Address - Country:US
Mailing Address - Phone:1952-830-8017
Mailing Address - Fax:
Practice Address - Street 1:7550 FRANCE AVE S STE 240
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4821
Practice Address - Country:US
Practice Address - Phone:952-830-8017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1856171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty