Provider Demographics
NPI:1417306267
Name:PETERSEN, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13561 LAKES WAY
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-8154
Mailing Address - Country:US
Mailing Address - Phone:407-388-8305
Mailing Address - Fax:
Practice Address - Street 1:13561 LAKES WAY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-8154
Practice Address - Country:US
Practice Address - Phone:407-388-8305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-11
Last Update Date:2016-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH12418101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health