Provider Demographics
NPI:1982191847
Name:PETERSON, GRETCHEN ELSA (LICSW)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:ELSA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3395 PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-3765
Mailing Address - Country:US
Mailing Address - Phone:952-939-0396
Mailing Address - Fax:952-548-8760
Practice Address - Street 1:3395 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305
Practice Address - Country:US
Practice Address - Phone:952-939-0396
Practice Address - Fax:952-548-8760
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical