Provider Demographics
NPI:1972696102
Name:PETERSON, CYNTHIA A (MA, LP, LPCC, RPT)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MA, LP, LPCC, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14665 GALAXIE AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-4509
Mailing Address - Country:US
Mailing Address - Phone:952-431-6033
Mailing Address - Fax:952-431-3225
Practice Address - Street 1:14665 GALAXIE AVE STE 140
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-4509
Practice Address - Country:US
Practice Address - Phone:952-431-6033
Practice Address - Fax:952-431-3225
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5107103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling