MEDICARE: DR. KRISTA PETERSON PSY.D.L.P.

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	5777	MN
2	103TC0700X	Clinical Psychologist	5777	MN

General Provider Information

NPI Number	:	1538559810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KRISTA PETERSON PSY.D.L.P.

Provider Business Mailing Address
First Line	:	6600 FRANCE AVE S STE 230
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-1810
Country	:	US
Telephone Number	:	952-460-2084
Fax Number	:

Provider Business Practice Location Address
First Line	:	6600 FRANCE AVE S STE 230
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-1810
Country	:	US
Telephone Number	:	952-460-2084
Fax Number	:

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

Provider Enumeration Date	:	01/26/2015
Last Update Date	:	01/26/2015

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