Provider Demographics
NPI:1568628592
Name:PETERSON, VICKI SUE (MSW)
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:SUE
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 1:501 LEXINGTON ST APT 73
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-3039
Mailing Address - Country:US
Mailing Address - Phone:781-899-6629
Mailing Address - Fax:781-899-2769
Practice Address - Street 1:501 LEXINGTON ST APT 73
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-3039
Practice Address - Country:US
Practice Address - Phone:781-899-6629
Practice Address - Fax:781-899-2769
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101818106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist