Provider Demographics
NPI:1821166653
Name:PETERSON, PATRICIA MARY
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:MARY
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 1:13657 ELKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-5233
Mailing Address - Country:US
Mailing Address - Phone:612-325-4018
Mailing Address - Fax:952-892-1722
Practice Address - Street 1:1500 MCANDREWS RD W
Practice Address - Street 2:SUITE 224
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4432
Practice Address - Country:US
Practice Address - Phone:612-325-4018
Practice Address - Fax:952-892-1722
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3202103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN65D24PEOtherBLUE CROSS BLUE SHIELD
MN65D25PEOtherBLUE CROSS BLUE SHIELD