Provider Demographics
NPI:1982612453
Name:PETERSEN, NEAL AARON (MSSW)
Entity Type:Individual
Prefix:MR
First Name:NEAL
Middle Name:AARON
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MSSW
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 364
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094
Mailing Address - Country:US
Mailing Address - Phone:920-261-4100
Mailing Address - Fax:920-261-8801
Practice Address - Street 1:1315 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094
Practice Address - Country:US
Practice Address - Phone:920-261-4100
Practice Address - Fax:920-261-8801
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16801231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1011421OtherPHYSICIANS PLUS INS
WI39184249626OtherUNITY INSURANCE
WI39184249627OtherUNITY INSURANCE
WI10056OtherDEON HEALTH INS
WI166358OtherMHN INSURANCE
WI39623200Medicaid