Provider Demographics
NPI:1982379723
Name:PETERSON, ALICIA (MSW, APSW)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSW, APSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 COUNTY ROAD H
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:WI
Mailing Address - Zip Code:54007-7517
Mailing Address - Country:US
Mailing Address - Phone:715-808-2993
Mailing Address - Fax:
Practice Address - Street 1:150 W 1ST ST STE 270
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-1770
Practice Address - Country:US
Practice Address - Phone:715-246-4840
Practice Address - Fax:715-254-9459
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13072-120104100000X
WI132818-1211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker