Provider Demographics
NPI:1801406392
Name:PETERSON, LILLIAN J (LISW-S)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHILDRENS PLZ
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45404-1873
Mailing Address - Country:US
Mailing Address - Phone:937-641-4757
Mailing Address - Fax:
Practice Address - Street 1:1 CHILDRENS PLZ
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-1873
Practice Address - Country:US
Practice Address - Phone:937-641-4757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.21030341041C0700X
IL149.019228101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical