1487059952 NPI number — MS. BRITTANY ANNE PETERSON MSW, QMHP

Table of content: MS. BRITTANY ANNE PETERSON MSW, QMHP (NPI 1487059952)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487059952 NPI number — MS. BRITTANY ANNE PETERSON MSW, QMHP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
BRITTANY
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, QMHP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOONEY
Provider Other First Name:
BRITTANY
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1487059952
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2025 WASHINGTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUKEGAN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60085-5131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-360-1020
Provider Business Mailing Address Fax Number:
847-360-1065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2025 WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUKEGAN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60085-5131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-360-1020
Provider Business Practice Location Address Fax Number:
847-360-1065
Provider Enumeration Date:
10/27/2014

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: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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