1003925876 NPI number — JOAN CASSILLY PETERSEN LCSW

Table of content: JOAN CASSILLY PETERSEN LCSW (NPI 1003925876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003925876 NPI number — JOAN CASSILLY PETERSEN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSEN
Provider First Name:
JOAN
Provider Middle Name:
CASSILLY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003925876
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PERSONAL POTENTIALS, INC.
Provider Second Line Business Mailing Address:
10000 WATSON RD #2L18
Provider Business Mailing Address City Name:
ST LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-822-4727
Provider Business Mailing Address Fax Number:
314-822-0531

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PERSONAL POTENTIALS, INC.
Provider Second Line Business Practice Location Address:
10000 WATSON RD #2L18
Provider Business Practice Location Address City Name:
ST LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-822-4727
Provider Business Practice Location Address Fax Number:
314-822-0531
Provider Enumeration Date:
08/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  000296 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 005794000 . This is a "MBH NETWORK PROVIDER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 064401 . This is a "V/O NETWORK PROVIDER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6122 . This is a "BCBS NETWORK PROVIDER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 111252 . This is a "A/B NETWORK PROVIDER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 185524 . This is a "COMPSYCH NETWORK PROVIDER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 493289102 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6267853 . This is a "UBH NETWORK PROVIDER" identifier . This identifiers is of the category "OTHER".




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