Provider Demographics
NPI:1144581653
Name:PETERSON, LISA (CSW INTERN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CSW INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 AVENUE F
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:NV
Mailing Address - Zip Code:89301-3500
Mailing Address - Country:US
Mailing Address - Phone:775-289-1671
Mailing Address - Fax:775-289-1699
Practice Address - Street 1:1675 AVENUE F
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:NV
Practice Address - Zip Code:89301-3500
Practice Address - Country:US
Practice Address - Phone:775-289-1671
Practice Address - Fax:775-289-1699
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker