Provider Demographics
NPI:1093446866
Name:PETERSMARK, DAVID (LSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PETERSMARK
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 752123
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77275-2123
Mailing Address - Country:US
Mailing Address - Phone:312-476-9064
Mailing Address - Fax:312-900-8230
Practice Address - Street 1:1448 N MILWAUKEE AVE STE 201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-6412
Practice Address - Country:US
Practice Address - Phone:312-476-9064
Practice Address - Fax:312-900-8230
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150106843104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker