Provider Demographics
NPI:1134817042
Name:PETERSON, CALLIE K (MA, LMFT)
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:K
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5346 LYNDALE AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-1230
Mailing Address - Country:US
Mailing Address - Phone:651-365-8237
Mailing Address - Fax:612-746-5518
Practice Address - Street 1:5346 LYNDALE AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-1230
Practice Address - Country:US
Practice Address - Phone:651-365-8237
Practice Address - Fax:612-746-5518
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4319106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist