Provider Demographics
NPI:1831246073
Name:PETERSON, CARLA (MS, LPC)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 HEIGHTS DR
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6146
Mailing Address - Country:US
Mailing Address - Phone:715-832-8432
Mailing Address - Fax:715-832-5007
Practice Address - Street 1:2125 HEIGHTS DR
Practice Address - Street 2:SUITE 2D
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6146
Practice Address - Country:US
Practice Address - Phone:715-832-8432
Practice Address - Fax:715-832-5007
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2897-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39792100Medicaid