Provider Demographics
NPI:1487746244
Name:PETERSEN, GORDON WAYNE (MSW, LICSW)
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:WAYNE
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:763 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-2728
Mailing Address - Country:US
Mailing Address - Phone:802-862-9067
Mailing Address - Fax:
Practice Address - Street 1:166 BATTERY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-5283
Practice Address - Country:US
Practice Address - Phone:802-862-3373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00001421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical