Provider Demographics
NPI:1518014372
Name:PETTERSEN, LINDA CARTER (MSW)
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:CARTER
Last Name:PETTERSEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 MONONA DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53716-3554
Mailing Address - Country:US
Mailing Address - Phone:608-663-0763
Mailing Address - Fax:608-663-0765
Practice Address - Street 1:5900 MONONA DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53716-3554
Practice Address - Country:US
Practice Address - Phone:608-663-0763
Practice Address - Fax:608-663-0765
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2547-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39533200Medicaid
WI39533200Medicaid