Provider Demographics
NPI:1124738141
Name:PETERSON, WAVERLY RAE (LMSW)
Entity type:Individual
Prefix:
First Name:WAVERLY
Middle Name:RAE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 CANTINA SKY DR
Mailing Address - Street 2:
Mailing Address - City:LEANDER
Mailing Address - State:TX
Mailing Address - Zip Code:78641-3707
Mailing Address - Country:US
Mailing Address - Phone:512-484-2086
Mailing Address - Fax:
Practice Address - Street 1:1101 SATELLITE VW UNIT 603
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-1592
Practice Address - Country:US
Practice Address - Phone:512-862-0687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-30
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1040401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical