Provider Demographics
NPI:1104070952
Name:PEDERSEN, STEPHANIE P (LP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:P
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5125 COUNTY ROAD 101, SUITE 300
Mailing Address - Street 2:RELATE, INC.
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345
Mailing Address - Country:US
Mailing Address - Phone:952-932-7277
Mailing Address - Fax:952-932-9827
Practice Address - Street 1:5125 COUNTY ROAD 101, SUITE 300
Practice Address - Street 2:RELATE, INC.
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345
Practice Address - Country:US
Practice Address - Phone:952-932-7277
Practice Address - Fax:952-932-9827
Is Sole Proprietor?:No
Enumeration Date:2008-11-06
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 4964103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist