Provider Demographics
NPI:1033889811
Name:PETERSON, ISLA MARIE (LLMSW)
Entity Type:Individual
Prefix:
First Name:ISLA
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 PINE AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-4119
Mailing Address - Country:US
Mailing Address - Phone:616-990-8930
Mailing Address - Fax:
Practice Address - Street 1:560 SEMINOLE RD
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-3720
Practice Address - Country:US
Practice Address - Phone:231-733-8686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511063611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical