Provider Demographics
NPI:1508489410
Name:PETERSON, CHANDRA NICOLE (LCSW)
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:NICOLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6363 DE ZAVALA RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-2104
Mailing Address - Country:US
Mailing Address - Phone:210-399-4838
Mailing Address - Fax:
Practice Address - Street 1:6363 DE ZAVALA RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-2103
Practice Address - Country:US
Practice Address - Phone:210-399-4838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX550711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty