Provider Demographics
NPI:1659982445
Name:PETERSON, SHANNON E
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:E
Last Name:PETERSON
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 1:309 COURT AVE STE 241
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-2282
Mailing Address - Country:US
Mailing Address - Phone:515-901-2974
Mailing Address - Fax:515-875-4817
Practice Address - Street 1:309 COURT AVE STE 241
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-2282
Practice Address - Country:US
Practice Address - Phone:515-901-2974
Practice Address - Fax:308-398-6051
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1123471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical