Provider Demographics
NPI:1922252188
Name:PETERSON, PAULA MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:PAULA
Other - Middle Name:MARIE
Other - Last Name:SIPPY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:505 S DEWEY ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-3704
Mailing Address - Country:US
Mailing Address - Phone:715-832-1678
Mailing Address - Fax:715-832-6680
Practice Address - Street 1:505 S DEWEY ST
Practice Address - Street 2:SUITE 208
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-3704
Practice Address - Country:US
Practice Address - Phone:715-832-1678
Practice Address - Fax:715-832-6680
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3934-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3934-125OtherSTATE OF WI LPC LICENTURE
WI43719000Medicaid