Provider Demographics
NPI:1235850538
Name:PETERSON, KATIE S (LMSW)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:S
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 MARY ST
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-4519
Mailing Address - Country:US
Mailing Address - Phone:208-201-9286
Mailing Address - Fax:
Practice Address - Street 1:403 RIVERFRONT DR
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-5162
Practice Address - Country:US
Practice Address - Phone:208-742-1110
Practice Address - Fax:208-742-1120
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-42637104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker