Healthcare Provider Details

I. General information

NPI: 1053897546
Provider Name (Legal Business Name): KARI LYNN PETERSEN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2702 CUNNINGHAM AVE STE A
JOPLIN MO
64804-1593
US

IV. Provider business mailing address

2702 CUNNINGHAM AVE STE A
JOPLIN MO
64804-1593
US

V. Phone/Fax

Practice location:
  • Phone: 417-782-1910
  • Fax: 417-782-1844
Mailing address:
  • Phone: 417-782-1910
  • Fax: 417-782-1844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: