Basic Information
| Provider Information | |||||||||
| NPI: | 1053307025 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | LUANN | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21078 115TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | THIEF RIVER FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567019313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186813658 | ||||||||
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| Practice Location | |||||||||
| Address1: | 120 LABREE AVE S | ||||||||
| Address2: | NORTHWEST MEDICAL CENTER | ||||||||
| City: | THIEF RIVER FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567012819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186814240 | ||||||||
| FaxNumber: | 2186815614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 4847 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 09493300 | 05 | MN | MEDICAID | 336L2PE | 01 | MN | BCBS | OTHER |