Provider Demographics
NPI:1306562996
Name:PETERS, VANESSA (LCSW)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CORTLAND CT
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-6481
Mailing Address - Country:US
Mailing Address - Phone:270-317-6117
Mailing Address - Fax:
Practice Address - Street 1:204 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-1417
Practice Address - Country:US
Practice Address - Phone:270-360-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2572431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY257243OtherMEDICARE