Provider Demographics
NPI:1124352174
Name:PETERSEN, REBECCA LEE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VACCINIUM WAY
Mailing Address - Street 2:
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-2809
Mailing Address - Country:US
Mailing Address - Phone:860-227-6839
Mailing Address - Fax:
Practice Address - Street 1:147 DURHAM RD
Practice Address - Street 2:OAK PARK
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-2675
Practice Address - Country:US
Practice Address - Phone:860-227-6839
Practice Address - Fax:860-227-6839
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0086971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical