Provider Demographics
NPI:1922420082
Name:PETERSEN, SCOTT (DBH, LMFT, LISAC)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DBH, LMFT, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 S DOBSON RD STE 201
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-6457
Mailing Address - Country:US
Mailing Address - Phone:480-371-4516
Mailing Address - Fax:
Practice Address - Street 1:2204 S DOBSON RD STE 201
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-6457
Practice Address - Country:US
Practice Address - Phone:480-371-4516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-09
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11778101YA0400X
AZLMFT-10277106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)