Provider Demographics
NPI:1629170790
Name:PETERSEN, ANN RENEE (LPCC, NCC)
Entity Type:Individual
Prefix:MS
First Name:ANN
Middle Name:RENEE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LPCC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3237
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-3237
Mailing Address - Country:US
Mailing Address - Phone:505-400-9913
Mailing Address - Fax:
Practice Address - Street 1:4686 CORRALES RD
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-8610
Practice Address - Country:US
Practice Address - Phone:505-400-9913
Practice Address - Fax:505-890-1527
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2009-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0069062101YM0800X
NM0098101101YP2500X
NM0119911101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM33007829Medicaid
NM615695OtherVALUE OPTIONS
NM613923500OtherOFFICE OF WORKERS' COMPENSATIONS PROGRAMS, FECA, DEPT OF LABOR
NM201-047-937OtherPRESBYTERIAN HEALTH PLANS
NM0000036606OtherSTATE OF NM, DEPT. OF VOCATIONAL REHAB
NM10012607OtherLOVELACE PROVIDER ID