Provider Demographics
NPI:1295246841
Name:PETERSON, ANASTASIA
Entity type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4014 GREGORY DR
Mailing Address - Street 2:
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099-1342
Mailing Address - Country:US
Mailing Address - Phone:708-307-9631
Mailing Address - Fax:
Practice Address - Street 1:13135 W 21ST ST
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:IL
Practice Address - Zip Code:60083-9319
Practice Address - Country:US
Practice Address - Phone:847-731-3192
Practice Address - Fax:847-731-3194
Is Sole Proprietor?:No
Enumeration Date:2017-10-21
Last Update Date:2017-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.007968101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health