Basic Information
| Provider Information | |||||||||
| NPI: | 1972078251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | KYLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9859 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581069859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014514900 | ||||||||
| FaxNumber: | 6519250057 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 1ST ST SW STE 250 | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587013851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018523328 | ||||||||
| FaxNumber: | 6519250057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2018 | ||||||||
| LastUpdateDate: | 10/12/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 980-10-15-18A | ND | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.