Healthcare Provider Details

I. General information

NPI: 1023859212
Provider Name (Legal Business Name): ISABELLA PETERSON LPC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 FORDEM AVE
MADISON WI
53704-4604
US

IV. Provider business mailing address

1716 FORDEM AVE
MADISON WI
53704-4604
US

V. Phone/Fax

Practice location:
  • Phone: 608-221-3511
  • Fax: 608-221-3514
Mailing address:
  • Phone: 608-221-3514
  • Fax: 608-221-3514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9132226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: