Provider Demographics
NPI:1346764859
Name:PETERSON, CONNIE KAROL
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:KAROL
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1891 E ROSEVILLE PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-7974
Mailing Address - Country:US
Mailing Address - Phone:916-789-7082
Mailing Address - Fax:
Practice Address - Street 1:1891 E ROSEVILLE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-7974
Practice Address - Country:US
Practice Address - Phone:916-789-7082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82428106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106H00000XOtherMARRIAGE AND FAMILY THERAPIST