Provider Demographics
NPI:1336384726
Name:PETERSON, LINDA ANNIE (LPT)
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:ANNIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 STINSON AVE
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-3831
Mailing Address - Country:US
Mailing Address - Phone:707-446-8905
Mailing Address - Fax:707-452-7387
Practice Address - Street 1:584 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-2779
Practice Address - Country:US
Practice Address - Phone:530-661-3213
Practice Address - Fax:530-661-3027
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27931101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health