Provider Demographics
NPI:1992280218
Name:PETERS, TANYA LYNN (MS, LPC, SAC-IT)
Entity type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:LYNN
Last Name:PETERS
Suffix:
Gender:F
Credentials:MS, LPC, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N53W27805 BANTRY RD
Mailing Address - Street 2:
Mailing Address - City:SUSSEX
Mailing Address - State:WI
Mailing Address - Zip Code:53089-4535
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9224 W BURLEIGH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-3503
Practice Address - Country:US
Practice Address - Phone:414-367-9869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-02
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18534-130101YA0400X
WI7314-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)