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General NPI Number Information
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NPI Number | 1134691165
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Entity Type | Individual
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Provider Name | DANIELL SUE PETERSON
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Gender | Female
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Dates
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Enumeration Date | 01/02/2019
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Last Update Date | 01/08/2019
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Provider Practice Location Address
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Address Line | 1711 OSCEOLA AVE STE 115
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City | CHARITON
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State | IA
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Zip | 50049-1516
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Country | US
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Telephone | 641-774-8484
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Fax |
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Provider Business Mailing Address
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Address Line | 302 NE 14TH ST
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City | LEON
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State | IA
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Zip | 50144-1206
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 19000
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License Number State | IA
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