Provider Demographics
NPI:1063652238
Name:LAURA PETERSEN, M.S.W., L.C.S.W., L.L.C.
Entity Type:Organization
Organization Name:LAURA PETERSEN, M.S.W., L.C.S.W., L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:812-369-7683
Mailing Address - Street 1:901 S ROGERS ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4756
Mailing Address - Country:US
Mailing Address - Phone:812-369-7683
Mailing Address - Fax:
Practice Address - Street 1:901 S ROGERS ST
Practice Address - Street 2:SUITE 202
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4756
Practice Address - Country:US
Practice Address - Phone:812-369-7683
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-02
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004770A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200887530AMedicaid
IN608950CGMedicare UPIN