Basic Information
| Provider Information | |||||||||
| NPI: | 1396843413 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEDERSON | ||||||||
| FirstName: | CORTNEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SIDWELL | ||||||||
| OtherFirstName: | CORTNEY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW LICSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6600 FRANCE AVE S | ||||||||
| Address2: | STE 230 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554351805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528352002 | ||||||||
| FaxNumber: | 9528359889 | ||||||||
| Practice Location | |||||||||
| Address1: | 6600 FRANCE AVE S | ||||||||
| Address2: | STE 320 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554351805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528352002 | ||||||||
| FaxNumber: | 9528359889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 01/22/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 15940 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 4045202 | 01 | MN | UCARE | OTHER | 4045202 | 01 | MN | BHP | OTHER | 954694400 | 05 | MN | MEDICAID | 199P1ST | 01 | MN | BCBS | OTHER | HP49679 | 01 | MN | HEALTH PARTNERS | OTHER |