Healthcare Provider Details

I. General information

NPI: 1235659996
Provider Name (Legal Business Name): PAMELA SUE PETERSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2017
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4136 LEGACY PKWY
LANSING MI
48911-4265
US

IV. Provider business mailing address

2230 MAPLE DR
JACKSON MI
49203-3623
US

V. Phone/Fax

Practice location:
  • Phone: 517-882-3732
  • Fax:
Mailing address:
  • Phone: 517-849-2333
  • Fax: 517-796-2785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401008493
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: