Provider Demographics
NPI:1518356484
Name:PETERSEN ENTERPRISES INC
Entity Type:Organization
Organization Name:PETERSEN ENTERPRISES INC
Other - Org Name:INNOVATIVE NEUROFEEDBACK THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:970-234-1147
Mailing Address - Street 1:4213 DURANGO PL
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-4103
Mailing Address - Country:US
Mailing Address - Phone:970-234-1147
Mailing Address - Fax:
Practice Address - Street 1:4529 STOVER ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3261
Practice Address - Country:US
Practice Address - Phone:970-234-1147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2179101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty