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General NPI Number Information
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NPI Number | 1316754955
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Entity Type | Individual
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Provider Name | TINA LEANNE PETERSON MA, LPCC
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Gender | Female
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Dates
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Enumeration Date | 12/17/2024
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Last Update Date | 12/17/2024
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Provider Practice Location Address
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Address Line | 100 ARAPAHOE AVE STE 14
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City | BOULDER
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State | CO
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Zip | 80302-5862
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Country | US
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Telephone | 616-540-3990
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Fax |
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Provider Business Mailing Address
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Address Line | 100 ARAPAHOE AVE STE 14
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City | BOULDER
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State | CO
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Zip | 80302-5862
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Country | US
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Telephone | 616-540-3990
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPCC.0022838
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License Number State | CO
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