Provider Demographics
NPI:1275018491
Name:PETERS, EMILY (LPC)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:PETERS
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 1:25480 W CEDAR CREST LN
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-8256
Mailing Address - Country:US
Mailing Address - Phone:847-356-8205
Mailing Address - Fax:
Practice Address - Street 1:25480 W CEDAR CREST LN
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-9744
Practice Address - Country:US
Practice Address - Phone:847-356-8205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178013112101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL178013112OtherILLINOIS STATE PROFESSIONAL LICENSE