Provider Demographics
NPI:1760534416
Name:PETERSON, THERESA ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4845 W LAKE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2973
Mailing Address - Country:US
Mailing Address - Phone:814-218-3054
Mailing Address - Fax:814-725-0707
Practice Address - Street 1:4845 W LAKE RD STE 102
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-2973
Practice Address - Country:US
Practice Address - Phone:814-218-3054
Practice Address - Fax:814-725-0707
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW015447101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health