Provider Demographics
NPI:1962514869
Name:PETERSON, LISA A (LMHC LCDP LCDCS MAC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMHC LCDP LCDCS MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02907-2423
Mailing Address - Country:US
Mailing Address - Phone:401-432-6029
Mailing Address - Fax:401-300-5656
Practice Address - Street 1:110 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-2423
Practice Address - Country:US
Practice Address - Phone:401-432-6029
Practice Address - Fax:401-300-5656
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILCDP00129103TA0400X
RIMHC00235101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI412210OtherBLUE CHIP
RI29290 8OtherBLUE CROSS
RILJ55332Medicaid