Provider Demographics
NPI:1265758114
Name:PETERS, HEATHER J (PHD, LP, CC-AASP)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:J
Last Name:PETERS
Suffix:
Gender:F
Credentials:PHD, LP, CC-AASP
Other - Prefix:DR
Other - First Name:HEATHER
Other - Middle Name:J
Other - Last Name:STEFANEK-PETERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, LP, CC-AASP
Mailing Address - Street 1:12012 430TH AVE
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:MN
Mailing Address - Zip Code:56267-4559
Mailing Address - Country:US
Mailing Address - Phone:320-250-4813
Mailing Address - Fax:
Practice Address - Street 1:205 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:MN
Practice Address - Zip Code:56267-2104
Practice Address - Country:US
Practice Address - Phone:320-250-4813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-18
Last Update Date:2010-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5219103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical