Provider Demographics
NPI:1851354153
Name:PETERSON, MICHELLE C (MS LMFT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:C
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 PARKLAWN AVENUE,
Mailing Address - Street 2:380
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4300
Mailing Address - Country:US
Mailing Address - Phone:612-203-2961
Mailing Address - Fax:952-831-0033
Practice Address - Street 1:7600 PARKLAWN AVE
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:612-203-2961
Practice Address - Fax:952-831-0033
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1315106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN990991045225OtherPREFERRED ONE
1639343783OtherORGANIZATIONAL NPI
918142300OtherMEDICAL ASSISTANCE
MN918142300Medicaid