Provider Demographics
NPI:1235659996
Name:PETERSON, PAMELA SUE (LPC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-3623
Mailing Address - Country:US
Mailing Address - Phone:517-849-2333
Mailing Address - Fax:517-796-2785
Practice Address - Street 1:4136 LEGACY PKWY
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4265
Practice Address - Country:US
Practice Address - Phone:517-882-3732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008493101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional