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General NPI Number Information
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NPI Number | 1437535580
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Entity Type | Organization
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Legal Business Name | REBECCA L. PETERSEN, LCSW, LLC
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Dates
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Enumeration Date | 07/30/2015
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Last Update Date | 07/30/2015
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Provider Practice Location Address
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Address Line | 147 DURHAM RD OAK PARK
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City | MADISON
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State | CT
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Zip | 06443-2675
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Country | US
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Telephone | 860-227-6839
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Fax |
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Provider Business Mailing Address
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Address Line | 1 VACCINIUM WAY
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City | OLD LYME
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State | CT
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Zip | 06371-2809
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Country | US
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Telephone | 860-227-6839
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Fax | 203-643-2204
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Authorized Official
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Title or Position | OWNER/PSYCHOTHERAPIST
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Name | MRS. REBECCA LEE PETERSEN
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Credential | LCSW
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Telephone | 860-227-6839
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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 | 008697
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License Number State | CT
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