Provider Demographics
NPI:1215567243
Name:PETERSON, LADY MARIE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:LADY
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MRS
Other - First Name:LADY
Other - Middle Name:MARIE
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:1 GUSTAVE L. LEVY PLACE, NEW YORK
Mailing Address - Street 2:
Mailing Address - City:NY
Mailing Address - State:NY
Mailing Address - Zip Code:10029
Mailing Address - Country:US
Mailing Address - Phone:212-731-7968
Mailing Address - Fax:
Practice Address - Street 1:1 GUSTAVE L. LEVY PLACE, NEW YORK
Practice Address - Street 2:
Practice Address - City:NY
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-731-7968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0943000104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker