Provider Demographics
NPI:1225365315
Name:PETERSEN, ELISE
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:PETERSEN
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 1:18 CLAREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-5812
Mailing Address - Country:US
Mailing Address - Phone:781-648-6200
Mailing Address - Fax:781-646-9106
Practice Address - Street 1:18 CLAREMONT AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-5812
Practice Address - Country:US
Practice Address - Phone:781-648-6200
Practice Address - Fax:781-646-9106
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator