Provider Demographics
NPI:1497845788
Name:PETERSEN, DAVID (LCSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N TEJON ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1101
Mailing Address - Country:US
Mailing Address - Phone:719-332-6767
Mailing Address - Fax:
Practice Address - Street 1:6200 S SYRACUSE WAY STE 260
Practice Address - Street 2:
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-4739
Practice Address - Country:US
Practice Address - Phone:719-332-6767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO81101YA0400X
CO2551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO099366Medicaid
CO549978Medicare ID - Type Unspecified