Healthcare Provider Details

I. General information

NPI: 1043777949
Provider Name (Legal Business Name): ELIZABETH PETERSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 MAIN ST
WILLIMANTIC CT
06226-1910
US

IV. Provider business mailing address

2 WATERSIDE XING STE 401
WINDSOR CT
06095-1588
US

V. Phone/Fax

Practice location:
  • Phone: 607-315-5228
  • Fax: 860-731-5536
Mailing address:
  • Phone: 860-697-3351
  • Fax: 860-731-5536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: