Provider Demographics
NPI:1609344399
Name:PETERSON, NATASHA (LCPC)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4132 E JOPPA RD STE 110-1131
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-2272
Mailing Address - Country:US
Mailing Address - Phone:410-260-0667
Mailing Address - Fax:
Practice Address - Street 1:4132 E JOPPA RD STE 110-1131
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-2272
Practice Address - Country:US
Practice Address - Phone:410-260-0667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-11
Last Update Date:2019-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC9091101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health