Provider Demographics
NPI:1952852436
Name:PETERSEN, BETSY PACK (LMSW)
Entity Type:Individual
Prefix:
First Name:BETSY
Middle Name:PACK
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:BETSY
Other - Middle Name:LEANNE
Other - Last Name:PACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:2267 TETON PLZ
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6486
Mailing Address - Country:US
Mailing Address - Phone:208-522-0140
Mailing Address - Fax:208-524-7335
Practice Address - Street 1:2267 TETON PLZ
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6486
Practice Address - Country:US
Practice Address - Phone:208-522-0140
Practice Address - Fax:208-524-7335
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-38030104100000X, 101Y00000X
TN10930 (LMSW)104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker