Provider Demographics
NPI:1093268146
Name:PETERSON, LA VONCIA REGAN (LCSWA)
Entity Type:Individual
Prefix:MRS
First Name:LA VONCIA
Middle Name:REGAN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 W. RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:ROSE HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28458
Mailing Address - Country:US
Mailing Address - Phone:910-289-2610
Mailing Address - Fax:
Practice Address - Street 1:416 W. RIDGE ST
Practice Address - Street 2:
Practice Address - City:ROSE HILL
Practice Address - State:NC
Practice Address - Zip Code:28458
Practice Address - Country:US
Practice Address - Phone:910-289-2610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-25
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0105841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical