Provider Demographics
NPI:1346254935
Name:PETERSEN, MICHAEL WAYNE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1249 FARRAGUT CIR
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-6364
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2750 SUTTERVILLE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-1024
Practice Address - Country:US
Practice Address - Phone:916-290-8155
Practice Address - Fax:916-456-4636
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA202211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical