Provider Demographics
NPI:1710392956
Name:PETERSON, CYNTHIA MICHELLE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:MICHELLE
Last Name:PETERSON
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 1:15 STATE ST STE 305
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5166
Mailing Address - Country:US
Mailing Address - Phone:207-217-2434
Mailing Address - Fax:
Practice Address - Street 1:15 STATE ST STE 305
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5166
Practice Address - Country:US
Practice Address - Phone:207-217-2434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC111711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1710392956Medicaid