Provider Demographics
NPI:1710320890
Name:PETERSON, MATA MARIE (LSW, LADC)
Entity Type:Individual
Prefix:MS
First Name:MATA
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LSW, LADC
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 703
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56538-0703
Mailing Address - Country:US
Mailing Address - Phone:701-640-8915
Mailing Address - Fax:218-643-7175
Practice Address - Street 1:227 6TH ST N
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MN
Practice Address - Zip Code:56520-1503
Practice Address - Country:US
Practice Address - Phone:701-640-8915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15452104100000X
MN301596101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker