Provider Demographics
NPI:1053737684
Name:PETERSON, MEGHANN ROSE (LICSW)
Entity type:Individual
Prefix:
First Name:MEGHANN
Middle Name:ROSE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:MEGHANN
Other - Middle Name:ROSE
Other - Last Name:HARTMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:1100 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-1430
Mailing Address - Country:US
Mailing Address - Phone:612-871-1454
Mailing Address - Fax:612-871-1505
Practice Address - Street 1:1100 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-1430
Practice Address - Country:US
Practice Address - Phone:612-871-1454
Practice Address - Fax:612-871-1505
Is Sole Proprietor?:No
Enumeration Date:2014-03-06
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN209691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical