Healthcare Provider Details

I. General information

NPI: 1891389847
Provider Name (Legal Business Name): DANNA M. PETERSON, LPC, CMHC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2021
Last Update Date: 02/21/2021
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2252 KINGMAN AVE
KINGMAN AZ
86401-4838
US

IV. Provider business mailing address

2252 KINGMAN AVE
KINGMAN AZ
86401-4838
US

V. Phone/Fax

Practice location:
  • Phone: 602-510-0665
  • Fax: 765-227-4798
Mailing address:
  • Phone: 602-510-0665
  • Fax: 765-227-4798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: DANNA MARIE PETERSON
Title or Position: PROVIDER
Credential: M.ED.
Phone: 602-510-0665