Provider Demographics
NPI:1972674091
Name:PETERSON, PAMELA MARJORIE (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:MARJORIE
Last Name:PETERSON
Suffix:
Gender:F
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 1:314 DEVIN DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MN
Mailing Address - Zip Code:55972-1701
Mailing Address - Country:US
Mailing Address - Phone:507-421-1064
Mailing Address - Fax:507-523-3661
Practice Address - Street 1:300 W BROADWAY
Practice Address - Street 2:STE 1
Practice Address - City:PLAINVIEW
Practice Address - State:MN
Practice Address - Zip Code:55964-1256
Practice Address - Country:US
Practice Address - Phone:507-421-1064
Practice Address - Fax:507-932-8556
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3975103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN607316600Medicaid
MN607316600Medicaid
MNP49313Medicare UPIN