Provider Demographics
NPI:1902813124
Name:PETERSON, SARA ALICE (LPC)
Entity Type:Individual
Prefix:MS
First Name:SARA
Middle Name:ALICE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 E PACES FERRY RD NE
Mailing Address - Street 2:SUITE 312
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-3313
Mailing Address - Country:US
Mailing Address - Phone:414-429-2411
Mailing Address - Fax:
Practice Address - Street 1:455 E PACES FERRY RD NE
Practice Address - Street 2:SUITE 312
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-3313
Practice Address - Country:US
Practice Address - Phone:414-429-2411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006395101YP2500X
WI3595-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41008400Medicaid