Provider Demographics
NPI:1053747576
Name:PETERSEN, KATHLEEN C (LCSW)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:C
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:ANN
Other - Last Name:CAVANAGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:591 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-3062
Mailing Address - Country:US
Mailing Address - Phone:847-757-5050
Mailing Address - Fax:
Practice Address - Street 1:591 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-3062
Practice Address - Country:US
Practice Address - Phone:847-757-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490148701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical