Provider Demographics
NPI:1942209481
Name:PETERSON, ROBERT LYNN (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LYNN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 4TH AVE W
Mailing Address - Street 2:GOVERNMENT CENTER RM 300
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-1220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 4TH AVE W
Practice Address - Street 2:GOVERNMENT CENTER RM 300
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-1220
Practice Address - Country:US
Practice Address - Phone:952-496-8401
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2415103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical