Provider Demographics
NPI:1063707305
Name:PETERSEN, LISA M (LMHP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7261 MERCY RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2311
Mailing Address - Country:US
Mailing Address - Phone:402-398-6248
Mailing Address - Fax:402-829-8513
Practice Address - Street 1:801 HARMONY ST
Practice Address - Street 2:SUITE 302
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-3106
Practice Address - Country:US
Practice Address - Phone:712-328-2609
Practice Address - Fax:712-328-9257
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8871101Y00000X
IA001501101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor