Provider Demographics
NPI:1154905651
Name:BROOKE PETERSEN COUNSELING PLLC
Entity type:Organization
Organization Name:BROOKE PETERSEN COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:N
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:630-803-1062
Mailing Address - Street 1:547 S CLARK ST APT 1001
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-1547
Mailing Address - Country:US
Mailing Address - Phone:630-803-1062
Mailing Address - Fax:
Practice Address - Street 1:3609 N MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3820
Practice Address - Country:US
Practice Address - Phone:630-803-1062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180013512OtherLCPC