Provider Demographics
NPI:1235131566
Name:PETERS, SALLY A (CSW)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:A
Last Name:PETERS
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3405 FONTANA LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-0109
Mailing Address - Country:US
Mailing Address - Phone:631-793-2846
Mailing Address - Fax:
Practice Address - Street 1:3405 FONTANA LAKE DR
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-0109
Practice Address - Country:US
Practice Address - Phone:631-793-2846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061437-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNV3671Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
NYP30634Medicare UPIN