Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor |
NPI | 1003284886 |
---|---|
Provider Name | Stephen Peterson |
First Address | Bloomington, MN 55431-1904 |
Second Address | Edina, MN 55439-2321 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/09/2015 |
Last Update Date | 09/09/2015 |