Healthcare Provider Details

I. General information

NPI: 1174453419
Provider Name (Legal Business Name): PAUL S. PETERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4148 WINNETKA AVE N
NEW HOPE MN
55427-1210
US

IV. Provider business mailing address

4148 WINNETKA AVE N
NEW HOPE MN
55427-1210
US

V. Phone/Fax

Practice location:
  • Phone: 763-504-8000
  • Fax:
Mailing address:
  • Phone: 763-504-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number406834
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: