Provider Demographics
NPI:1396115549
Name:PETERSON, ANSLEY AUTUMN (MSW)
Entity type:Individual
Prefix:
First Name:ANSLEY
Middle Name:AUTUMN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1510
Mailing Address - Country:US
Mailing Address - Phone:509-838-4651
Mailing Address - Fax:509-363-2762
Practice Address - Street 1:7 S HOWARD ST STE 321
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201
Practice Address - Country:US
Practice Address - Phone:509-838-4128
Practice Address - Fax:509-838-4816
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW607934651041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1396115549Medicaid