Provider Demographics
NPI:1073243150
Name:PETERSON, EMELYN (LCSW, MSW, MA/SSP)
Entity type:Individual
Prefix:
First Name:EMELYN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW, MSW, MA/SSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 W CENTRAL AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6800
Mailing Address - Country:US
Mailing Address - Phone:406-546-8529
Mailing Address - Fax:406-540-1432
Practice Address - Street 1:725 W CENTRAL AVE STE 208
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6800
Practice Address - Country:US
Practice Address - Phone:406-546-8529
Practice Address - Fax:406-540-1432
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCSW-LIC-741021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical