Provider Demographics
NPI:1659984037
Name:PETERSEN, BRITTANY J
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:J
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRITTANY
Other - Middle Name:J
Other - Last Name:AYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2526
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-2526
Mailing Address - Country:US
Mailing Address - Phone:417-347-7600
Mailing Address - Fax:
Practice Address - Street 1:307 W 11TH ST
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:MO
Practice Address - Zip Code:64759-1428
Practice Address - Country:US
Practice Address - Phone:417-347-8010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020028432101YP2500X
MO202002768106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist