Provider Demographics
NPI:1679113823
Name:PETERSON, SUSAN R
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2031 ROWLAND RD
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-7119
Mailing Address - Country:US
Mailing Address - Phone:320-364-1300
Mailing Address - Fax:320-323-2558
Practice Address - Street 1:2031 ROWLAND RD
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-7119
Practice Address - Country:US
Practice Address - Phone:320-364-1300
Practice Address - Fax:320-323-2558
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN220131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical