Provider Demographics
NPI:1457340614
Name:PETERSON, NADINE JOANNE (LP)
Entity type:Individual
Prefix:
First Name:NADINE
Middle Name:JOANNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 N CHARLES ST
Mailing Address - Street 2:#228
Mailing Address - City:NORTH SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109
Mailing Address - Country:US
Mailing Address - Phone:651-307-0282
Mailing Address - Fax:
Practice Address - Street 1:2440 N CHARLES ST
Practice Address - Street 2:#228
Practice Address - City:NORTH SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109
Practice Address - Country:US
Practice Address - Phone:651-307-0282
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1003103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8122539002Medicaid