Provider Demographics
NPI:1386758183
Name:PETERSEN, SCOTT R (LCSW, CADC, CAC-III)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:R
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:LCSW, CADC, CAC-III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 201630
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-7630
Mailing Address - Country:US
Mailing Address - Phone:312-515-3090
Mailing Address - Fax:
Practice Address - Street 1:2111 CHAMPA ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-2529
Practice Address - Country:US
Practice Address - Phone:303-312-9588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490108981041C0700X
CO15661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical