Provider Demographics
NPI:1407627193
Name:PETERSON, DEBRA (LMSW)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 N CAPITAL AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3405
Mailing Address - Country:US
Mailing Address - Phone:208-552-0855
Mailing Address - Fax:208-523-1132
Practice Address - Street 1:855 N CAPITAL AVE STE 1
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3405
Practice Address - Country:US
Practice Address - Phone:208-552-0855
Practice Address - Fax:208-523-1132
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-43948101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty