Provider Demographics
NPI:1003925876
Name:PETERSEN, JOAN CASSILLY (LCSW)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:CASSILLY
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PERSONAL POTENTIALS, INC.
Mailing Address - Street 2:10000 WATSON RD #2L18
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126
Mailing Address - Country:US
Mailing Address - Phone:314-822-4727
Mailing Address - Fax:314-822-0531
Practice Address - Street 1:PERSONAL POTENTIALS, INC.
Practice Address - Street 2:10000 WATSON RD #2L18
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126
Practice Address - Country:US
Practice Address - Phone:314-822-4727
Practice Address - Fax:314-822-0531
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0002961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
005794000OtherMBH NETWORK PROVIDER
064401OtherV/O NETWORK PROVIDER
6122OtherBCBS NETWORK PROVIDER
111252OtherA/B NETWORK PROVIDER
185524OtherCOMPSYCH NETWORK PROVIDER
MO493289102Medicaid
6267853OtherUBH NETWORK PROVIDER
064401OtherV/O NETWORK PROVIDER