Provider Demographics
NPI:1558077388
Name:PETERSON, CORIE (MSW)
Entity Type:Individual
Prefix:
First Name:CORIE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14900 BOGLE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-1757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14900 BOGLE DR STE 200
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1757
Practice Address - Country:US
Practice Address - Phone:703-817-9890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical