Provider Demographics
NPI:1386270205
Name:PETERSON, LYNDA CANNEZZARO (MSED, LP, LCDC, NBC)
Entity type:Individual
Prefix:MS
First Name:LYNDA
Middle Name:CANNEZZARO
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSED, LP, LCDC, NBC
Other - Prefix:MRS
Other - First Name:LYNDA
Other - Middle Name:CANNEZZARO
Other - Last Name:FELDT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:JUST MARRIED
Mailing Address - Street 1:2822 MEADOW BROOK CT
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-4344
Mailing Address - Country:US
Mailing Address - Phone:954-644-9521
Mailing Address - Fax:
Practice Address - Street 1:2822 MEADOW BROOK CT
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-4344
Practice Address - Country:US
Practice Address - Phone:954-644-9521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13912101YA0400X
TX78008101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX13912OtherTEXAS STATE BOARD OF EXAMINERS OF PROFESSIONAL COUNSELORS
TX78008OtherTEXAS STATE BOARD OF EXAMINERS OF PROFESSIONAL COUNSELORS
TX833028OtherNATIONAL BOARD CERTIFIED COUNSELOR