Provider Demographics
NPI:1063558047
Name:PETERSON, JANICE LOUISE (RN, LPC)
Entity type:Individual
Prefix:MRS
First Name:JANICE
Middle Name:LOUISE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 N SAM HOUSTON PKWY E
Mailing Address - Street 2:SUITE 525
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77060-4037
Mailing Address - Country:US
Mailing Address - Phone:281-999-8400
Mailing Address - Fax:281-999-8402
Practice Address - Street 1:525 N SAM HOUSTON PKWY E
Practice Address - Street 2:SUITE 525
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77060-4037
Practice Address - Country:US
Practice Address - Phone:281-999-8400
Practice Address - Fax:281-999-8402
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17543101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10016277OtherAMERIGROUP ID
TX478064OtherVALUE OPTIONS PROVIDER ID
TX148937901Medicaid
TX6098LCOtherBCBS ID
TX0007793396OtherAETNA ID
TX347889000OtherMAGELLAN HLTH ID
TX478064OtherVALUE OPTIONS PROVIDER ID