Provider Demographics
NPI:1437535580
Name:REBECCA L. PETERSEN, LCSW, LLC
Entity type:Organization
Organization Name:REBECCA L. PETERSEN, LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-227-6839
Mailing Address - Street 1:1 VACCINIUM WAY
Mailing Address - Street 2:
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-2809
Mailing Address - Country:US
Mailing Address - Phone:860-227-6839
Mailing Address - Fax:203-643-2204
Practice Address - Street 1:147 DURHAM RD
Practice Address - Street 2:OAK PARK
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-2675
Practice Address - Country:US
Practice Address - Phone:860-227-6839
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0086971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008056034Medicaid