Provider Demographics
NPI:1356647143
Name:NICHOLS-PETERSON, PENNY JO (LISW)
Entity Type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:JO
Last Name:NICHOLS-PETERSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:PENNY
Other - Middle Name:J
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:4517 49TH PL
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-2969
Mailing Address - Country:US
Mailing Address - Phone:515-802-7348
Mailing Address - Fax:515-255-3944
Practice Address - Street 1:6955 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:WINDSOR HEIGHTS
Practice Address - State:IA
Practice Address - Zip Code:50324-1540
Practice Address - Country:US
Practice Address - Phone:515-802-7348
Practice Address - Fax:515-255-3944
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-27
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0072601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical