Provider Demographics
NPI:1922551597
Name:PETERSON, EILEEN MARIE (MA)
Entity Type:Individual
Prefix:MRS
First Name:EILEEN
Middle Name:MARIE
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 1:3833 COON RAPIDS BLVD NW
Mailing Address - Street 2:SUITE 120
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2643
Mailing Address - Country:US
Mailing Address - Phone:763-767-3350
Mailing Address - Fax:763-767-0912
Practice Address - Street 1:207 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-4667
Practice Address - Country:US
Practice Address - Phone:763-367-6080
Practice Address - Fax:763-263-7897
Is Sole Proprietor?:No
Enumeration Date:2016-07-29
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MN3566106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health