Provider Demographics
NPI:1770365165
Name:PETERSEN VILLASENOR, HEATHER KRISTINA (AMFT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:KRISTINA
Last Name:PETERSEN VILLASENOR
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1611
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLEN
Mailing Address - State:CA
Mailing Address - Zip Code:95442-1611
Mailing Address - Country:US
Mailing Address - Phone:707-757-3206
Mailing Address - Fax:
Practice Address - Street 1:2227 CAPRICORN WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5478
Practice Address - Country:US
Practice Address - Phone:707-565-1303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health