Provider Demographics
NPI:1144845850
Name:PETERS, VANESSA MARIE (APSW)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:MARIE
Last Name:PETERS
Suffix:
Gender:F
Credentials:APSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7613 70TH AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-4021
Mailing Address - Country:US
Mailing Address - Phone:262-331-1281
Mailing Address - Fax:
Practice Address - Street 1:3001 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3048
Practice Address - Country:US
Practice Address - Phone:224-610-1261
Practice Address - Fax:224-610-2958
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI131639-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI131639-121OtherWISCONSIN STATE LICENSING