Provider Demographics
NPI:1578196598
Name:PETERSEN, VICTORIA L (LSW)
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:L
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 CAROL AVENUE
Mailing Address - Street 2:
Mailing Address - City:OAKHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07755
Mailing Address - Country:US
Mailing Address - Phone:732-278-6339
Mailing Address - Fax:
Practice Address - Street 1:116 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747
Practice Address - Country:US
Practice Address - Phone:732-290-9040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ11368001041S0200X
NJ44SL06519600104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool