Provider Demographics
NPI:1114016607
Name:PETERSEN-LUKENDA, LARRA RAE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRA
Middle Name:RAE
Last Name:PETERSEN-LUKENDA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4101 WOOLWORTH AVE.
Mailing Address - Street 2:VA NEBRASKA-WESTERN IOWA HEALTHCARE SYSTEM
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68105
Mailing Address - Country:US
Mailing Address - Phone:402-995-4486
Mailing Address - Fax:402-995-4562
Practice Address - Street 1:4101 WOOLWORTH AVE.
Practice Address - Street 2:VA NEBRASKA-WESTERN IOWA HEALTHCARE SYSTEM
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105
Practice Address - Country:US
Practice Address - Phone:402-995-4486
Practice Address - Fax:402-995-4562
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE654103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE280550Medicare PIN