Provider Demographics
NPI:1639602592
Name:PETERSON, ELISA (PSYD)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:ELISA
Other - Middle Name:
Other - Last Name:LEBMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2830 228TH AVE SE STE D
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98075-9300
Mailing Address - Country:US
Mailing Address - Phone:425-677-0966
Mailing Address - Fax:
Practice Address - Street 1:2830 228TH AVE SE STE D
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98075-9300
Practice Address - Country:US
Practice Address - Phone:425-677-0966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-07
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60711540103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling