Provider Demographics
NPI:1164927299
Name:PETERMAN, MORGAN DALE (MSW LSW)
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:DALE
Last Name:PETERMAN
Suffix:
Gender:F
Credentials:MSW LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3454 OAK ALLEY CT STE 510
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-5526
Mailing Address - Country:US
Mailing Address - Phone:567-218-0185
Mailing Address - Fax:419-930-6721
Practice Address - Street 1:3454 OAK ALLEY CT STE 510
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-5526
Practice Address - Country:US
Practice Address - Phone:567-218-0185
Practice Address - Fax:419-930-6721
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
OHI.2102776104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0276805Medicaid