Healthcare Provider Details

I. General information

NPI: 1972674091
Provider Name (Legal Business Name): PAMELA MARJORIE PETERSON PHD, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2006
Last Update Date: 04/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W BROADWAY STE 1
PLAINVIEW MN
55964-1256
US

IV. Provider business mailing address

314 DEVIN DR
SAINT CHARLES MN
55972-1701
US

V. Phone/Fax

Practice location:
  • Phone: 507-421-1064
  • Fax: 507-932-8556
Mailing address:
  • Phone: 507-421-1064
  • Fax: 507-523-3661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP3975
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: