Healthcare Provider Details

I. General information

NPI: 1285462937
Provider Name (Legal Business Name): MADELINE ROSE PEART LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2024
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 SE 13TH ST
GRAND RAPIDS MN
55744-0015
US

IV. Provider business mailing address

303 SE 1ST ST
GRAND RAPIDS MN
55744-3681
US

V. Phone/Fax

Practice location:
  • Phone: 218-999-9908
  • Fax:
Mailing address:
  • Phone: 218-360-2184
  • Fax: 218-999-7068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number29581
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: