=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033544119
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL ROBERT PETERSON LMFT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2013
-----------------------------------------------------
Last Update Date | 01/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 522 4TH ST S
-----------------------------------------------------
City | STILLWATER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55082-4966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-220-6038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6201 SAINT CROIX TRL N APT 119
-----------------------------------------------------
City | OAK PARK HEIGHTS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55082-6966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-220-6038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 1565
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------