Provider Demographics
NPI:1447490552
Name:PETERSON, KAREN LYNN (LCSW)
Entity type:Individual
Prefix:MS
First Name:KAREN
Middle Name:LYNN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:KAREN
Other - Middle Name:LYNN
Other - Last Name:ROTTKAMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:6 BIRCH CT
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-3923
Mailing Address - Country:US
Mailing Address - Phone:516-426-9183
Mailing Address - Fax:
Practice Address - Street 1:363 ROUTE 111
Practice Address - Street 2:SUITE 103
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-4756
Practice Address - Country:US
Practice Address - Phone:516-426-9183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-02
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY076169-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical