1851354153 NPI number — MICHELLE C PETERSON MS LMFT

Table of content: MICHELLE C PETERSON MS LMFT (NPI 1851354153)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851354153 NPI number — MICHELLE C PETERSON MS LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
MICHELLE
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS LMFT
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:
1851354153
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7600 PARKLAWN AVENUE,
Provider Second Line Business Mailing Address:
380
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55435-4300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-203-2961
Provider Business Mailing Address Fax Number:
952-831-0033

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7600 PARKLAWN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-203-2961
Provider Business Practice Location Address Fax Number:
952-831-0033
Provider Enumeration Date:
04/08/2006

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: 106H00000X , with the licence number:  1315 , 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: 990991045225 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1639343783 . This is a "ORGANIZATIONAL NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 918142300 . This is a "MEDICAL ASSISTANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 918142300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".