Healthcare Provider Details

I. General information

NPI: 1518688720
Provider Name (Legal Business Name): BETHANY PETERSON, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2022
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3523 45TH ST S
FARGO ND
58104-8962
US

IV. Provider business mailing address

110 15TH ST SE
BARNESVILLE MN
56514-3315
US

V. Phone/Fax

Practice location:
  • Phone: 218-329-9345
  • Fax:
Mailing address:
  • Phone: 218-329-9345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: BETHANY PETERSON
Title or Position: CLINICAL SOCIAL WORKER
Credential: MSW, LICSW, LAC
Phone: 218-329-9345