Provider Demographics
NPI:1669927273
Name:PEAK, PORSCHE (LMFT, LADC)
Entity type:Individual
Prefix:
First Name:PORSCHE
Middle Name:
Last Name:PEAK
Suffix:
Gender:F
Credentials:LMFT, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2864 MIDDLE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LITTLE CANADA
Mailing Address - State:MN
Mailing Address - Zip Code:55117-1411
Mailing Address - Country:US
Mailing Address - Phone:651-493-2055
Mailing Address - Fax:651-340-8632
Practice Address - Street 1:2864 MIDDLE ST STE 100
Practice Address - Street 2:
Practice Address - City:LITTLE CANADA
Practice Address - State:MN
Practice Address - Zip Code:55117-1411
Practice Address - Country:US
Practice Address - Phone:651-493-2055
Practice Address - Fax:651-340-8632
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304885101YA0400X
101YM0800X
MN3415106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health