MEDICARE: DR. SUSAN PETERS PSYD, 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	LP3237	MN

General Provider Information

NPI Number	:	1780666958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN PETERS PSYD, LP

Provider Business Mailing Address
First Line	:	14587 GRAND AVE
Second Line	:	#201
City	:	BURNSVILLE
State	:	MN
Zip	:	55306-5700
Country	:	US
Telephone Number	:	952-953-7087
Fax Number	:

Provider Business Practice Location Address
First Line	:	14587 GRAND AVE
Second Line	:	#201
City	:	BURNSVILLE
State	:	MN
Zip	:	55306-5700
Country	:	US
Telephone Number	:	952-953-7087
Fax Number	:

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

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	07/08/2007

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