Provider Demographics
NPI:1285478776
Name:PETERSEN, LYDIA (LGSW, LADC)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LGSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1367 WILLOW ST APT 308
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-2578
Mailing Address - Country:US
Mailing Address - Phone:507-381-5920
Mailing Address - Fax:
Practice Address - Street 1:5354 PARKDALE DR FL 3
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1603
Practice Address - Country:US
Practice Address - Phone:919-287-6274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305955101YA0400X
MN32713101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty