1831605203 NPI number — SUSAN ELAINE PETERSON-BONES LICSW

Table of content: KIMBERLY BETH SNYDER (NPI 1609588714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831605203 NPI number — SUSAN ELAINE PETERSON-BONES LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON-BONES
Provider First Name:
SUSAN
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831605203
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1212 E COLLEGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARSHALL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56258-2010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-532-3236
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
818 PRENTICE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANITE FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-564-2238
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/21/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  10392 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10392 . This is a "LICENSE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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