Provider Demographics
NPI:1801038948
Name:PETERSON, LISA MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
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 1:7816 NW MILREY DR
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64152-2141
Mailing Address - Country:US
Mailing Address - Phone:816-507-1981
Mailing Address - Fax:
Practice Address - Street 1:215 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:MO
Practice Address - Zip Code:63555-1425
Practice Address - Country:US
Practice Address - Phone:660-465-7790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080322171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical