Active NPI
Joan Cassilly Petersen, LCSW
- Clinical Social Worker
- St Louis, MO
National Provider Identifier
1003925876
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- License
- 000296
- Practice address
- Personal Potentials, Inc.
10000 Watson Rd #2L18
St Louis, MO 63126 - Phone
- (314) 822-4727
- Fax
- (314) 822-0531
- NPI assigned
- Aug 29, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | 000296 | MO | Primary |
Addresses
Primary practice location
Personal Potentials, Inc.
10000 Watson Rd #2L18
St Louis, MO 63126
Mailing address
Personal Potentials, Inc.
10000 Watson Rd #2L18
St Louis, MO 63126
Phone (314) 822-4727
Other identifiers 7
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 005794000 | Other | MBH NETWORK PROVIDER | |
| 064401 | Other | V/O NETWORK PROVIDER | |
| 6122 | Other | BCBS NETWORK PROVIDER | |
| 111252 | Other | A/B NETWORK PROVIDER | |
| 185524 | Other | COMPSYCH NETWORK PROVIDER | |
| 493289102 | Medicaid | MO | |
| 6267853 | Other | UBH NETWORK PROVIDER |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 000296 | MO | MD | Professional Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156809600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1220400000000",
"number": "1003925876",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PERSONAL POTENTIALS, INC.",
"address_2": "10000 WATSON RD #2L18",
"city": "ST LOUIS",
"state": "MO",
"postal_code": "63126",
"telephone_number": "314-822-4727",
"fax_number": "314-822-0531"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "PERSONAL POTENTIALS, INC.",
"address_2": "10000 WATSON RD #2L18",
"city": "ST LOUIS",
"state": "MO",
"postal_code": "63126",
"telephone_number": "314-822-4727",
"fax_number": "314-822-0531"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETERSEN",
"first_name": "JOAN",
"middle_name": "CASSILLY",
"credential": "LCSW",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-08-29",
"last_updated": "2008-09-03",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "MO",
"license": "000296",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MBH NETWORK PROVIDER",
"identifier": "005794000",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "V/O NETWORK PROVIDER",
"identifier": "064401",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS NETWORK PROVIDER",
"identifier": "6122",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "A/B NETWORK PROVIDER",
"identifier": "111252",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "COMPSYCH NETWORK PROVIDER",
"identifier": "185524",
"state": null
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "493289102",
"state": "MO"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "UBH NETWORK PROVIDER",
"identifier": "6267853",
"state": null
}
],
"endpoints": [],
"other_names": []
}Other providers in St Louis, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 3, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.