Provider Demographics
NPI:1447574025
Name:PETERSON, BETTY JOYCE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:BETTY
Middle Name:JOYCE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N BEACH ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111-7010
Mailing Address - Country:US
Mailing Address - Phone:817-916-5204
Mailing Address - Fax:817-916-4665
Practice Address - Street 1:400 N BEACH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76111-7010
Practice Address - Country:US
Practice Address - Phone:817-916-5204
Practice Address - Fax:817-916-4665
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX383581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical