Provider Demographics
NPI:1952969123
Name:PETERSON, NANCY NICOLE (LPC-MH)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:NICOLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPC-MH
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 83
Mailing Address - Street 2:
Mailing Address - City:CUSTER
Mailing Address - State:SD
Mailing Address - Zip Code:57730-0083
Mailing Address - Country:US
Mailing Address - Phone:605-673-3832
Mailing Address - Fax:
Practice Address - Street 1:1369 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:CUSTER
Practice Address - State:SD
Practice Address - Zip Code:57730-8246
Practice Address - Country:US
Practice Address - Phone:605-673-3832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC-MH30524101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health