Provider Demographics
NPI:1134691165
Name:PETERSON, DANIELL SUE
Entity Type:Individual
Prefix:
First Name:DANIELL
Middle Name:SUE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 NE 14TH ST
Mailing Address - Street 2:
Mailing Address - City:LEON
Mailing Address - State:IA
Mailing Address - Zip Code:50144-1206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1711 OSCEOLA AVE STE 115
Practice Address - Street 2:
Practice Address - City:CHARITON
Practice Address - State:IA
Practice Address - Zip Code:50049-1516
Practice Address - Country:US
Practice Address - Phone:641-774-8484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19000101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)