Provider Demographics
NPI:1366843963
Name:PETERSON, CARRIE
Entity type:Individual
Prefix:MRS
First Name:CARRIE
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 1:403 N GRAND AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-4913
Mailing Address - Country:US
Mailing Address - Phone:262-420-9088
Mailing Address - Fax:262-458-4102
Practice Address - Street 1:3200 W HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208
Practice Address - Country:US
Practice Address - Phone:414-342-4560
Practice Address - Fax:414-342-5326
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health