Healthcare Provider Details

I. General information

NPI: 1336981125
Provider Name (Legal Business Name): PEREGRINE PSYCHOTHERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 N 17TH AVE E
DULUTH MN
55812-1240
US

IV. Provider business mailing address

504 N 17TH AVE E
DULUTH MN
55812-1240
US

V. Phone/Fax

Practice location:
  • Phone: 608-213-3280
  • Fax:
Mailing address:
  • Phone: 608-213-3280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN MCCARTY
Title or Position: CLINICAL SOCIAL WORKER
Credential:
Phone: 608-213-3280