Provider Demographics
NPI:1275292112
Name:PETERSON, EMILY TRAVIS (LPC)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:TRAVIS
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 1:1537 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4386
Mailing Address - Country:US
Mailing Address - Phone:970-999-9422
Mailing Address - Fax:
Practice Address - Street 1:1506 W HORSETOOTH RD UNIT 6204
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-2893
Practice Address - Country:US
Practice Address - Phone:630-699-4993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0020194101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health