Provider Demographics
NPI:1699143149
Name:PETERSEN, JOSEPH (BS, LADC)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:BS, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 N ELM AVE
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-1736
Mailing Address - Country:US
Mailing Address - Phone:507-676-7573
Mailing Address - Fax:
Practice Address - Street 1:203 W CLARK ST
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2549
Practice Address - Country:US
Practice Address - Phone:507-377-5484
Practice Address - Fax:507-377-5505
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-14
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302594101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)