Provider Demographics
NPI:1942639562
Name:PETERSON, ANN MARIE (LSW)
Entity Type:Individual
Prefix:
First Name:ANN MARIE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6408 BRIARCLIFF CT
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-4204
Mailing Address - Country:US
Mailing Address - Phone:630-416-1252
Mailing Address - Fax:
Practice Address - Street 1:6408 BRIARCLIFF CT
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-4204
Practice Address - Country:US
Practice Address - Phone:630-416-1252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.014386104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker