Provider Demographics
NPI:1386961001
Name:PETERSON, KASSANDRA KAY (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:KAY
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:KASSANDRA
Other - Middle Name:
Other - Last Name:DALLMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1833 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-2424
Mailing Address - Country:US
Mailing Address - Phone:763-421-5535
Mailing Address - Fax:763-433-0226
Practice Address - Street 1:1833 3RD AVE
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-5353
Practice Address - Country:US
Practice Address - Phone:651-748-5019
Practice Address - Fax:651-773-7591
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1386961001Medicaid