Provider Demographics
NPI:1699942516
Name:PETESON, NICOLE LYNNE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LYNNE
Last Name:PETESON
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 1:2702 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-0102
Mailing Address - Country:US
Mailing Address - Phone:308-698-8060
Mailing Address - Fax:
Practice Address - Street 1:2702 W 11TH ST
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-0102
Practice Address - Country:US
Practice Address - Phone:308-698-8060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-09
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-687101YA0400X
NE8087101YM0800X
NE65201041C0700X
1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical