Provider Demographics
NPI:1992279152
Name:PETERS, SYDNEY K (LICSW)
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:K
Last Name:PETERS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 WOODLEY ST E
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-2957
Mailing Address - Country:US
Mailing Address - Phone:218-289-2422
Mailing Address - Fax:
Practice Address - Street 1:18598 ELK RIVER TRL
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55024
Practice Address - Country:US
Practice Address - Phone:651-333-0653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-21
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
MN31151101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator