Provider Demographics
NPI:1255875654
Name:PETERSON, DANIELLE E (CSAC, LPC)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:E
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CSAC, LPC
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:E
Other - Last Name:LISSNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSAC, LPC
Mailing Address - Street 1:850 E BROADWAY AVE APT A
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-1586
Mailing Address - Country:US
Mailing Address - Phone:715-965-1201
Mailing Address - Fax:
Practice Address - Street 1:429 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1608
Practice Address - Country:US
Practice Address - Phone:715-748-4312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-05
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17253-130101YA0400X
WI7067-125101YP2500X
WI3198-226101YP2500X
WI16281-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)