=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376884262
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARYANN MARIE PETERSEN LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2013
-----------------------------------------------------
Last Update Date | 06/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1223 N ROCK RD BLDG. G SUITE 100
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67206-1269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-636-2888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1215 N PRESCOTT ST
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67212-6820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-807-1037
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 2454
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------