Provider Demographics
NPI:1639705676
Name:PETERSEN, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5723 BRIDLESPUR LN
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5372
Mailing Address - Country:US
Mailing Address - Phone:248-761-5359
Mailing Address - Fax:
Practice Address - Street 1:5723 BRIDLESPUR LN
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5372
Practice Address - Country:US
Practice Address - Phone:248-761-5359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-22
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical