Provider Demographics
NPI:1306813548
Name:PETERSON, MARY L (MSW ACSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSW ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 RAYBROOK ST SE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7718
Mailing Address - Country:US
Mailing Address - Phone:616-942-8060
Mailing Address - Fax:616-942-6690
Practice Address - Street 1:2040 RAYBROOK SE
Practice Address - Street 2:SUITE 103
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-942-8060
Practice Address - Fax:616-942-6690
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010748471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N71880Medicare ID - Type Unspecified