Provider Demographics
NPI:1912297474
Name:PEDERSEN, MARILYN JEAN (LADC)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:JEAN
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 3RD AVE SW
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063-1468
Mailing Address - Country:US
Mailing Address - Phone:320-629-1362
Mailing Address - Fax:320-629-3454
Practice Address - Street 1:645 3RD AVE SW
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-1468
Practice Address - Country:US
Practice Address - Phone:320-629-1362
Practice Address - Fax:320-629-3454
Is Sole Proprietor?:No
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300700101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)