Healthcare Provider Details

I. General information

NPI: 1912858127
Provider Name (Legal Business Name): EMILY JOAN PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2026
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 NW 1ST AVE
GRAND RAPIDS MN
55744-2702
US

IV. Provider business mailing address

25184 NORTH RD
BOVEY MN
55709-8347
US

V. Phone/Fax

Practice location:
  • Phone: 218-360-1800
  • Fax:
Mailing address:
  • Phone: 218-360-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5437
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: