Provider Demographics
NPI:1659838142
Name:PETERSON, JULIE ANN (LADC)
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ANN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:RICHTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:640 JACKSON ST
Mailing Address - Street 2:MAILSTOP 11303C
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2595
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2595
Practice Address - Country:US
Practice Address - Phone:651-254-1440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305271101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)