Provider Demographics
NPI:1174347876
Name:PEDERSON, RHYLEE MARIE
Entity type:Individual
Prefix:
First Name:RHYLEE
Middle Name:MARIE
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 6TH AVE S # 407
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56563-1200
Mailing Address - Country:US
Mailing Address - Phone:218-280-0607
Mailing Address - Fax:
Practice Address - Street 1:4215 31ST AVE S STE A
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7743
Practice Address - Country:US
Practice Address - Phone:701-478-0221
Practice Address - Fax:701-478-0222
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNRBT-24-301172106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician