Provider Demographics
NPI:1134852064
Name:PEDERSON, KRISTEN JOY (LISW)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:JOY
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4123 NANCY PL
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-6411
Mailing Address - Country:US
Mailing Address - Phone:651-226-6982
Mailing Address - Fax:
Practice Address - Street 1:4123 NANCY PL
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-6411
Practice Address - Country:US
Practice Address - Phone:651-226-6982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121701041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool