Provider Demographics
NPI:1629056080
Name:PETERSON, CAROL B (ED D)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:B
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ED D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 NEW LA GRANGE RD
Mailing Address - Street 2:STE 312
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4870
Mailing Address - Country:US
Mailing Address - Phone:502-394-9990
Mailing Address - Fax:502-394-9992
Practice Address - Street 1:7400 NEW LA GRANGE RD
Practice Address - Street 2:STE 312
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4870
Practice Address - Country:US
Practice Address - Phone:502-394-9990
Practice Address - Fax:502-394-9992
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1140103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY130215OtherAPS
KY243740OtherUNITED BEHAVIORAL HEALTH
KY7830266OtherAETNA
KY89000129Medicaid
KY177855OtherCOMPSYCH
KY2144611OtherCIGNA
KY348656OtherMHN
KY273699000OtherMAGELLAN
KY000000174990OtherANTHEM
KY476947OtherVALUE OPTIONS
KY177855OtherCOMPSYCH
KY89000129Medicaid