Provider Demographics
NPI:1558867655
Name:PETERSON, MELISSA (LICSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:598 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-1513
Mailing Address - Country:US
Mailing Address - Phone:508-737-7093
Mailing Address - Fax:
Practice Address - Street 1:400 HUNNEWELL ST STE 6R
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494-1360
Practice Address - Country:US
Practice Address - Phone:508-737-7093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA118493104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker