Provider Demographics
NPI:1295991990
Name:PETERSON, EDI M (LPC)
Entity type:Individual
Prefix:
First Name:EDI
Middle Name:M
Last Name:PETERSON
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 1:201 HARBOR VIEW TER
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-1187
Mailing Address - Country:US
Mailing Address - Phone:201-312-5595
Mailing Address - Fax:
Practice Address - Street 1:44 E 32ND ST
Practice Address - Street 2:11TH FLOOR TRS PROFESSIONAL SUITES
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-5508
Practice Address - Country:US
Practice Address - Phone:212-685-2848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-01
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001758101YM0800X
NJ37PC00359600101YP2500X
TX16071101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional