Provider Demographics
NPI:1033672621
Name:PETERSON, STEPHANIE SLORAHN (LCSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SLORAHN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 GULF BREEZE PKW
Mailing Address - Street 2:BLDG 2, STE 4
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4468
Mailing Address - Country:US
Mailing Address - Phone:850-203-0045
Mailing Address - Fax:850-782-0656
Practice Address - Street 1:1101 GULF BREEZE PKW
Practice Address - Street 2:BLDG 2, STE 4
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4468
Practice Address - Country:US
Practice Address - Phone:850-203-0045
Practice Address - Fax:850-782-0656
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW65931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty