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General NPI Number Information
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NPI Number | 1265646590
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Entity Type | Organization
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Legal Business Name | ELLEN C PETERSON
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Dates
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Enumeration Date | 05/09/2007
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Last Update Date | 06/24/2008
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Provider Practice Location Address
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Address Line | 402 N CAYUGA ST
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City | ITHACA
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State | NY
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Zip | 14850
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Country | US
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Telephone | 607-272-7720
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Fax | 607-564-0554
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Provider Business Mailing Address
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Address Line | 402 N CAYUGA ST
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City | ITHACA
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State | NY
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Zip | 14850
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Country | US
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Telephone | 607-272-7720
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Fax | 607-564-0554
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Authorized Official
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Title or Position | OWNER PSYCHOTHERAPIST
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Name | ELLEN C PETERSON
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Credential | LCSW
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Telephone | 607-272-7720
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | PR0432461
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License Number State | NY
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