Provider Demographics
NPI:1902905516
Name:PEDERSEN, GWEN KATRINA (MS)
Entity Type:Individual
Prefix:MRS
First Name:GWEN
Middle Name:KATRINA
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 STEARNS WAY STE 111
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1275
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 25TH AVE S STE 109
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4820
Practice Address - Country:US
Practice Address - Phone:320-255-0343
Practice Address - Fax:320-654-0318
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1156106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist