Provider Demographics
NPI:1801432380
Name:PETERSON, ANGELA (LPC)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
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:PO BOX 50026
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79159-0026
Mailing Address - Country:US
Mailing Address - Phone:806-552-9700
Mailing Address - Fax:
Practice Address - Street 1:1901 MEDI PARK DR STE 216
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-2110
Practice Address - Country:US
Practice Address - Phone:806-552-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX20208101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX416078001Medicaid
TX77385OtherTEXAS STATE BOARD OF EXAMINERS OF PROFESSIONAL COUNSELORS