Healthcare Provider Details

I. General information

NPI: 1265646590
Provider Name (Legal Business Name): ELLEN C PETERSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 N CAYUGA ST
ITHACA NY
14850
US

IV. Provider business mailing address

402 N CAYUGA ST
ITHACA NY
14850
US

V. Phone/Fax

Practice location:
  • Phone: 607-272-7720
  • Fax: 607-564-0554
Mailing address:
  • Phone: 607-272-7720
  • Fax: 607-564-0554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberPR0432461
License Number StateNY

VIII. Authorized Official

Name: ELLEN C PETERSON
Title or Position: OWNER PSYCHOTHERAPIST
Credential: LCSW
Phone: 607-272-7720