Provider Demographics
NPI:1922336684
Name:PETERSON, ROBERT JOHN (LICSW)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40647 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LOON LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99148-9795
Mailing Address - Country:US
Mailing Address - Phone:099-395-5155
Mailing Address - Fax:
Practice Address - Street 1:40647 LAKE RD
Practice Address - Street 2:
Practice Address - City:LOON LAKE
Practice Address - State:WA
Practice Address - Zip Code:99148-9795
Practice Address - Country:US
Practice Address - Phone:509-939-5515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-18
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601745531041C0700X
NMX-06759104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM336712OtherPED LICENSE
NMX-06759OtherSTATE LICENSE