Healthcare Provider Details

I. General information

NPI: 1902905516
Provider Name (Legal Business Name): GWEN KATRINA PEDERSEN M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
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

2025 STEARNS WAY STE 111
SAINT CLOUD MN
56303-1275
US

V. Phone/Fax

Practice location:
  • Phone: 320-255-0343
  • Fax: 320-654-0318
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1156
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: