Provider Demographics
NPI:1003188897
Name:PETERSON, CORENE (LCSW)
Entity Type:Individual
Prefix:
First Name:CORENE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 E LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-2129
Mailing Address - Country:US
Mailing Address - Phone:208-524-8996
Mailing Address - Fax:208-524-1205
Practice Address - Street 1:1565 E LINCOLN RD
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-2129
Practice Address - Country:US
Practice Address - Phone:208-524-8996
Practice Address - Fax:208-524-1205
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-340381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical