| Doctor Name: | CORENE PETERSON |
| NPI Number: | 1003188897 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LCSW |
| License Number: | LCSW-34038 |
| Business Practice Address: | 1565 E Lincoln Rd Idaho Falls, ID - 834012129 |
| Business Phone Number: | 2085248996 |
| Business Fax Number: | 2085241205 |
| Mailing Address: | 1565 E Lincoln Rd, IDAHO FALLS |
| State: | ID |
| Postal Code: | 834012129 |
| Phone Number: | 2085248996 |
| Fax Number: | 2085241205 |
| NPI Enumeration Date: | 02/08/2012 |
| NPI Last Update Date: | 10/10/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | LCSW-34038 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ID |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |