Basic Information
| Provider Information | |||||||||
| NPI: | 1679962138 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | JAMESON | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 167 POLK ST # 6550 | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136012770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157827445 | ||||||||
| FaxNumber: | 3157791184 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 ELM ST | ||||||||
| Address2: | |||||||||
| City: | POTSDAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136762166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152615420 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2015 | ||||||||
| LastUpdateDate: | 12/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | P95835 | NY | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 089828 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.