Provider Demographics
NPI:1851100556
Name:PETERSON, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:MULDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3824 S PISIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57110-7671
Mailing Address - Country:US
Mailing Address - Phone:605-610-5473
Mailing Address - Fax:
Practice Address - Street 1:118 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LUVERNE
Practice Address - State:MN
Practice Address - Zip Code:56156-1829
Practice Address - Country:US
Practice Address - Phone:507-449-6105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4506101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health