Provider Demographics
NPI:1710083084
Name:PETERSEN, MARY LORRAINE (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LORRAINE
Last Name: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 1:705 HILLTOP CT
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727
Mailing Address - Country:US
Mailing Address - Phone:631-988-9812
Mailing Address - Fax:
Practice Address - Street 1:705 HILLTOP CT
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727
Practice Address - Country:US
Practice Address - Phone:631-696-4355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0232941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN10491Medicare ID - Type Unspecified