MEDICARE: EMILY JOAN PETERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	5437	MN

General Provider Information

NPI Number	:	1912858127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY JOAN PETERSON

Provider Business Mailing Address
First Line	:	25184 NORTH RD
Second Line	:
City	:	BOVEY
State	:	MN
Zip	:	55709-8347
Country	:	US
Telephone Number	:	218-360-1800
Fax Number	:

Provider Business Practice Location Address
First Line	:	217 NW 1ST AVE
Second Line	:
City	:	GRAND RAPIDS
State	:	MN
Zip	:	55744-2702
Country	:	US
Telephone Number	:	218-360-1800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/04/2026
Last Update Date	:	02/04/2026

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