Healthcare Provider Details

I. General information

NPI: 1053307025
Provider Name (Legal Business Name): SANDRA LUANN PETERSON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 LABREE AVE S NORTHWEST MEDICAL CENTER
THIEF RIVER FALLS MN
56701-2819
US

IV. Provider business mailing address

21078 115TH AVE NE
THIEF RIVER FALLS MN
56701-9313
US

V. Phone/Fax

Practice location:
  • Phone: 218-681-4240
  • Fax: 218-681-5614
Mailing address:
  • Phone: 218-681-3658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4847
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: