Provider Demographics
NPI:1477046837
Name:PETERSON, RACHEL MARIE
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:MARIE
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1630 PLUM ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-3462
Mailing Address - Country:US
Mailing Address - Phone:630-966-4475
Mailing Address - Fax:
Practice Address - Street 1:1630 PLUM ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-3462
Practice Address - Country:US
Practice Address - Phone:630-966-4475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health