Provider Demographics
NPI:1962554139
Name:PETERSEN, LAEL R (LCSW)
Entity type:Individual
Prefix:
First Name:LAEL
Middle Name:R
Last Name:PETERSEN
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 1:1980 WILLAMETTE FALLS DR
Mailing Address - Street 2:SUITE 240
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-4668
Mailing Address - Country:US
Mailing Address - Phone:503-656-2888
Mailing Address - Fax:503-656-2282
Practice Address - Street 1:1980 WILLAMETTE FALLS DR
Practice Address - Street 2:SUITE 240
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-4668
Practice Address - Country:US
Practice Address - Phone:503-656-2888
Practice Address - Fax:503-656-2282
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL36141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical