Provider Demographics
NPI:1104905272
Name:PETERSON, DAVID HEDDEN (LICSW)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:HEDDEN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 12TH ST SE
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-5437
Mailing Address - Country:US
Mailing Address - Phone:320-894-3450
Mailing Address - Fax:320-763-6629
Practice Address - Street 1:222 9TH AVE W
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2221
Practice Address - Country:US
Practice Address - Phone:320-763-3912
Practice Address - Fax:320-763-6629
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLICSW#21851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical