Provider Demographics
NPI:1225089840
Name:PETERSEN, CORBY J (LCSW)
Entity Type:Individual
Prefix:
First Name:CORBY
Middle Name:J
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:LCSW
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 770925
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-0925
Mailing Address - Country:US
Mailing Address - Phone:907-632-3403
Mailing Address - Fax:
Practice Address - Street 1:13135 OLD GLENN HWY
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7562
Practice Address - Country:US
Practice Address - Phone:907-632-3403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical