Provider Demographics
NPI:1750475430
Name:PETERSON, JOANNE (EDD)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:JOANNE
Other - Middle Name:E
Other - Last Name:HATTENDORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDD
Mailing Address - Street 1:40 BAYNARD COVE RD
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29928-4135
Mailing Address - Country:US
Mailing Address - Phone:815-409-6606
Mailing Address - Fax:843-363-9997
Practice Address - Street 1:40 BAYNARD COVE RD
Practice Address - Street 2:
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29928-4135
Practice Address - Country:US
Practice Address - Phone:815-409-6606
Practice Address - Fax:843-363-9997
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005887103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL219043OtherMAGELLAN
IL0991516762OtherBCBS
IL274154OtherVALUE BEHAVIORAL HEALTH