Provider Demographics
NPI:1942768064
Name:PETERSEN, ASHLEE (CADC I)
Entity type:Individual
Prefix:
First Name:ASHLEE
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43518 CARPENTER DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-4882
Mailing Address - Country:US
Mailing Address - Phone:310-487-2029
Mailing Address - Fax:
Practice Address - Street 1:12301 WILSHIRE BLVD STE 206
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1000
Practice Address - Country:US
Practice Address - Phone:310-487-2029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CI25040518101YA0400X
CACI25040518101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)