Provider Demographics
NPI:1902306616
Name:PETERSEN, STEPHANIE (LISW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1077 GORGE BLVD
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44310-2408
Mailing Address - Country:US
Mailing Address - Phone:234-312-5691
Mailing Address - Fax:234-312-2322
Practice Address - Street 1:55 ARCH ST STE 1B
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1436
Practice Address - Country:US
Practice Address - Phone:330-375-3315
Practice Address - Fax:330-375-3760
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.18008061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0292661Medicaid