Healthcare Provider Details

I. General information

NPI: 1750090858
Provider Name (Legal Business Name): GWEN PEDERSEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2022
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 25TH AVE S STE 109
SAINT CLOUD MN
56301-4820
US

IV. Provider business mailing address

600 25TH AVE S STE 109
SAINT CLOUD MN
56301-4820
US

V. Phone/Fax

Practice location:
  • Phone: 320-260-8313
  • Fax: 320-654-0318
Mailing address:
  • Phone: 320-260-8313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: GWEN PEDERSEN
Title or Position: MARRIAGE & FAMILY THERAPIST
Credential: MS, LMFT
Phone: 320-255-0343