Provider Demographics
NPI:1912533258
Name:PETERSEN, HEATHER LOUISE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:LOUISE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 WATERLINE DR
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-7735
Mailing Address - Country:US
Mailing Address - Phone:858-740-8337
Mailing Address - Fax:
Practice Address - Street 1:1020 WATERLINE DR
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-7735
Practice Address - Country:US
Practice Address - Phone:858-740-8337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA258661041C0700X
NCC0163571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty