Provider Demographics
NPI:1295881522
Name:PEDERSEN, ANNETTE JOHANNA (LPC)
Entity type:Individual
Prefix:MRS
First Name:ANNETTE
Middle Name:JOHANNA
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 GARRATY CT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-6177
Mailing Address - Country:US
Mailing Address - Phone:210-685-5099
Mailing Address - Fax:210-738-7789
Practice Address - Street 1:319 E MULBERRY AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-3024
Practice Address - Country:US
Practice Address - Phone:210-738-7780
Practice Address - Fax:210-738-7789
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20112101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional