Provider Demographics
NPI:1164876132
Name:PETERSON, SARA (MS, LCPC)
Entity Type:Individual
Prefix:MS
First Name:SARA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS, LCPC
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 35552
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5552
Mailing Address - Country:US
Mailing Address - Phone:702-970-4158
Mailing Address - Fax:310-756-1225
Practice Address - Street 1:6628 SKY POINTE DR STE 115
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131-4071
Practice Address - Country:US
Practice Address - Phone:702-970-4158
Practice Address - Fax:310-756-1225
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-15
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
NVCP1274101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional