Provider Demographics
NPI:1710403001
Name:PETERSEN, ELLEN (LISW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-4407
Mailing Address - Country:US
Mailing Address - Phone:319-874-3000
Mailing Address - Fax:
Practice Address - Street 1:1916 WATERFRONT DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-4416
Practice Address - Country:US
Practice Address - Phone:319-337-4523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA087080104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0076372Medicaid