MEDICARE: JUDITH MARIE PETERS LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	LP3425	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205061488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUDITH MARIE PETERS LP

Provider Business Mailing Address
First Line	:	PO BOX 2390
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56302-2390
Country	:	US
Telephone Number	:	320-650-1544
Fax Number	:	320-650-1528

Provider Business Practice Location Address
First Line	:	157 ROOSEVELT RD
Second Line	:	SUITE 300
City	:	SAINT CLOUD
State	:	MN
Zip	:	56301-5478
Country	:	US
Telephone Number	:	320-240-3324
Fax Number	:	320-240-3339

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2009
Last Update Date	:	05/18/2009

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