Healthcare Provider Details

I. General information

NPI: 1528976156
Provider Name (Legal Business Name): TRAVIS PETERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 MINNESOTA AVE NW
BEMIDJI MN
56601-3060
US

IV. Provider business mailing address

9329 OMAN RD NE
BEMIDJI MN
56601-8420
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-3100
  • Fax:
Mailing address:
  • Phone: 218-760-4599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number356362
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: