Provider Demographics
NPI:1194399303
Name:PETERSON, STEFANIE S (LGPC)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:S
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 FAIR WINDS WAY
Mailing Address - Street 2:
Mailing Address - City:OXON HILL
Mailing Address - State:MD
Mailing Address - Zip Code:20745-1192
Mailing Address - Country:US
Mailing Address - Phone:813-253-9747
Mailing Address - Fax:
Practice Address - Street 1:613 FAIR WINDS WAY
Practice Address - Street 2:
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-1192
Practice Address - Country:US
Practice Address - Phone:813-253-9747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP11387101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health