Provider Demographics
NPI:1336412659
Name:DELONG, PETER HEADLEY (LICSW)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:HEADLEY
Last Name:DELONG
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1846
Mailing Address - Country:US
Mailing Address - Phone:763-772-2217
Mailing Address - Fax:
Practice Address - Street 1:1600 E LAKE ST # 5
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1846
Practice Address - Country:US
Practice Address - Phone:763-772-2217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-16
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN193601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical