Provider Demographics
NPI:1033211883
Name:PETERSON, GAYLE (LCSW,PHD)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19861 BUCK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95949-7027
Mailing Address - Country:US
Mailing Address - Phone:530-346-2534
Mailing Address - Fax:530-346-2534
Practice Address - Street 1:19861 BUCK RIDGE RD
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95949-7027
Practice Address - Country:US
Practice Address - Phone:530-346-2534
Practice Address - Fax:530-346-2534
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical