Provider Demographics
NPI:1669647475
Name:BRADLEY-PETERSEN, ERIN MICHELLE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:MICHELLE
Last Name:BRADLEY-PETERSEN
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:PO BOX 758
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-0758
Mailing Address - Country:US
Mailing Address - Phone:845-342-5789
Mailing Address - Fax:
Practice Address - Street 1:41 DOLSON AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-6489
Practice Address - Country:US
Practice Address - Phone:845-342-5789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY079199-11041C0700X
NY072751-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker