Provider Demographics
NPI:1689193930
Name:PETERSON, SHARLA NICOLE (DSW)
Entity Type:Individual
Prefix:DR
First Name:SHARLA
Middle Name:NICOLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 STONE CREEK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MC GREGOR
Mailing Address - State:TX
Mailing Address - Zip Code:76657-4158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4800 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76711-1329
Practice Address - Country:US
Practice Address - Phone:254-297-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-18
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61825104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker