Provider Demographics
NPI:1134291008
Name:PETERSON, ANN M (LCSW-R)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 MORTON ST
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-1614
Mailing Address - Country:US
Mailing Address - Phone:518-483-2880
Mailing Address - Fax:518-483-5356
Practice Address - Street 1:209 PARK STREET
Practice Address - Street 2:CITIZEN ADVOCATES, INC.
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953
Practice Address - Country:US
Practice Address - Phone:518-483-3261
Practice Address - Fax:518-483-3383
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR039000-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBB9105Medicare ID - Type Unspecified
NYS98987Medicare UPIN