Provider Demographics
NPI:1861416687
Name:PETERSON WALZ, NANCY (LCSW)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:PETERSON WALZ
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 1:3908 CEDAR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60051
Mailing Address - Country:US
Mailing Address - Phone:815-276-2394
Mailing Address - Fax:815-363-5584
Practice Address - Street 1:2502 SPRING RIDGE DR
Practice Address - Street 2:STE F
Practice Address - City:SPRING GROVE
Practice Address - State:IL
Practice Address - Zip Code:60081-7812
Practice Address - Country:US
Practice Address - Phone:815-382-7029
Practice Address - Fax:815-363-5584
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490056371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01633897OtherBCBS GROUP PROVIDER NUMBE
IL207844Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER