Healthcare Provider Details

I. General information

NPI: 1346792256
Provider Name (Legal Business Name): DONNA PETERSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 14TH ST SW SUITE 250
WILLISTON ND
58801
US

IV. Provider business mailing address

PO BOX 96
RAY ND
58849-0096
US

V. Phone/Fax

Practice location:
  • Phone: 701-334-6242
  • Fax:
Mailing address:
  • Phone: 701-568-3385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5339
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number082344
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: