Basic Information
| Provider Information | |||||||||
| NPI: | 1003950312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 WOOD ST | ||||||||
| Address2: | HUMBOLDT COUNTY MENTAL HEALTH | ||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955014413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074457710 | ||||||||
| FaxNumber: | 7074764061 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 WOOD ST | ||||||||
| Address2: | HUMBOLDT COUNTY MENTAL HEALTH | ||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955014413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074457710 | ||||||||
| FaxNumber: | 7074764061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2007 | ||||||||
| LastUpdateDate: | 11/15/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 775420 | CA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.