Provider Demographics
NPI:1285652370
Name:PETERSON, A PERRIN (ACSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:A
Middle Name:PERRIN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:ACSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27192 SAN MARINO DR
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33983-3127
Mailing Address - Country:US
Mailing Address - Phone:941-626-8363
Mailing Address - Fax:
Practice Address - Street 1:27192 SAN MARINO DR
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33983-3127
Practice Address - Country:US
Practice Address - Phone:941-626-8363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC95241041C0700X
FLSW71011041C0700X
GACSW0022921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ034MOtherBCBS
ME412090099Medicaid
FLP92908Medicare UPIN
FLU0937AMedicare ID - Type Unspecified
MEME0914Medicare ID - Type UnspecifiedOUTPATIENT BEHAVIORAL HEA