Provider Demographics
NPI:1912747858
Name:PETERSEN, ASHLEY (LLPC)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3575 AUSTRIAN PINE WAY APT 6B
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-3933
Mailing Address - Country:US
Mailing Address - Phone:248-520-2237
Mailing Address - Fax:
Practice Address - Street 1:8080 MOORSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4421
Practice Address - Country:US
Practice Address - Phone:248-520-2237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023623101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty