Healthcare Provider Details

I. General information

NPI: 1962514869
Provider Name (Legal Business Name): LISA A PETERSON LMHC LCDP LCDCS MAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 ELMWOOD AVE
PROVIDENCE RI
02907-2423
US

IV. Provider business mailing address

110 ELMWOOD AVE
PROVIDENCE RI
02907-2423
US

V. Phone/Fax

Practice location:
  • Phone: 401-432-6029
  • Fax: 401-300-5656
Mailing address:
  • Phone: 401-432-6029
  • Fax: 401-300-5656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberLCDP00129
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC00235
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: