Provider Demographics
NPI:1063891638
Name:PETERSEN, BRETT (LMSW)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 N COUNTRY CLUB DR
Mailing Address - Street 2:BUILDING #1
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-4108
Mailing Address - Country:US
Mailing Address - Phone:480-969-3800
Mailing Address - Fax:480-307-9771
Practice Address - Street 1:4250 E FLORIAN AVE
Practice Address - Street 2:BUILDING #1
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2797
Practice Address - Country:US
Practice Address - Phone:480-844-1653
Practice Address - Fax:480-539-4979
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW155821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical