Provider Demographics
NPI:1710548623
Name:PETERSON, CASEY (MA)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 W 50TH ST # 250B
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-2047
Mailing Address - Country:US
Mailing Address - Phone:612-787-5121
Mailing Address - Fax:
Practice Address - Street 1:3801 W 50TH ST # 250B
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55410-2047
Practice Address - Country:US
Practice Address - Phone:612-787-5121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-23
Last Update Date:2019-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty