Healthcare Provider Details

I. General information

NPI: 1629170790
Provider Name (Legal Business Name): ANN RENEE PETERSEN L.P.C.C., N.C.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4686 CORRALES RD
CORRALES NM
87048-8610
US

IV. Provider business mailing address

PO BOX 3237
CORRALES NM
87048-3237
US

V. Phone/Fax

Practice location:
  • Phone: 505-400-9913
  • Fax: 505-890-1527
Mailing address:
  • Phone: 505-400-9913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0119911
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: