Provider Demographics
NPI:1699044818
Name:PETERSON, BARBARA LOIS (PHD, RN, CNS)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:LOIS
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHD, RN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 BLOOMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3074
Mailing Address - Country:US
Mailing Address - Phone:612-301-3433
Mailing Address - Fax:612-627-4205
Practice Address - Street 1:2001 BLOOMINGTON AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3074
Practice Address - Country:US
Practice Address - Phone:612-301-3433
Practice Address - Fax:612-627-4205
Is Sole Proprietor?:No
Enumeration Date:2011-12-16
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR84342-9163W00000X, 364SP0807X
MI4704231296163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health