Provider Demographics
NPI:1053985408
Name:PETERSON, ERIN
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1376 DALE ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-4126
Mailing Address - Country:US
Mailing Address - Phone:651-675-9714
Mailing Address - Fax:
Practice Address - Street 1:1376 DALE ST N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-4126
Practice Address - Country:US
Practice Address - Phone:651-675-9714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1-19-37417103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst