Provider Demographics
NPI:1265646590
Name:ELLEN C PETERSON
Entity Type:Organization
Organization Name:ELLEN C PETERSON
Other - Org Name:AVENUES COUNSELING CTR
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:607-272-7720
Mailing Address - Street 1:402 N CAYUGA ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850
Mailing Address - Country:US
Mailing Address - Phone:607-272-7720
Mailing Address - Fax:607-564-0554
Practice Address - Street 1:402 N CAYUGA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-272-7720
Practice Address - Fax:607-564-0554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR04324611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty