Provider Demographics
NPI:1285171801
Name:PETERSEN, SANDRA MARY BEDNARZ (LCPC)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:MARY BEDNARZ
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:MARY
Other - Last Name:BEDNARZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:115 QUEENSWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2517
Mailing Address - Country:US
Mailing Address - Phone:630-532-2793
Mailing Address - Fax:
Practice Address - Street 1:1900 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4273
Practice Address - Country:US
Practice Address - Phone:630-256-8007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-20
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178012647101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health