Provider Demographics
NPI:1457653529
Name:PETERSEN, MEIRA (LPCC)
Entity Type:Individual
Prefix:
First Name:MEIRA
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CALIENTE RD STE 2B
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-9102
Mailing Address - Country:US
Mailing Address - Phone:505-231-5481
Mailing Address - Fax:
Practice Address - Street 1:5 CALIENTE RD STE 2B
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-9102
Practice Address - Country:US
Practice Address - Phone:505-231-5481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-23
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0165401101YP2500X, 101YM0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12423451OtherCAQH
NM16505280Medicaid