Provider Demographics
NPI:1225703242
Name:PETERSON, CHRISTINE IRENE (LLMSW)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:IRENE
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 1:209 E WASHINGTON AVE STE 180-B
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2393
Mailing Address - Country:US
Mailing Address - Phone:517-262-9178
Mailing Address - Fax:
Practice Address - Street 1:209 E WASHINGTON AVE STE 180-B
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2393
Practice Address - Country:US
Practice Address - Phone:517-748-7075
Practice Address - Fax:517-748-7075
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-11
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511106631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical