Provider Demographics
NPI:1396297446
Name:PETERSON, LYNN R (MA, LPC)
Entity type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16351 I94 STE 204
Mailing Address - Street 2:
Mailing Address - City:SENTINEL BUTTE
Mailing Address - State:ND
Mailing Address - Zip Code:58654-9500
Mailing Address - Country:US
Mailing Address - Phone:701-872-3745
Mailing Address - Fax:
Practice Address - Street 1:16351 I94
Practice Address - Street 2:
Practice Address - City:SENTINEL BUTTE
Practice Address - State:ND
Practice Address - Zip Code:58654-9500
Practice Address - Country:US
Practice Address - Phone:701-872-3745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.008128101YP2500X
ND1087-10-1-20101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional