Provider Demographics
NPI:1407227036
Name:PETERSON, LAURIE (LISW)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4380 CORAL GABLES DR
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-6316
Mailing Address - Country:US
Mailing Address - Phone:440-882-6551
Mailing Address - Fax:
Practice Address - Street 1:4380 CORAL GABLES DR
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-6316
Practice Address - Country:US
Practice Address - Phone:440-882-6551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-08
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH104100000X
OHI.23048831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker