Provider Demographics
NPI:1720562903
Name:PETERSON, MITZI (MSW)
Entity Type:Individual
Prefix:
First Name:MITZI
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-3680
Mailing Address - Country:US
Mailing Address - Phone:508-422-3468
Mailing Address - Fax:
Practice Address - Street 1:50 MAPLE ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-3680
Practice Address - Country:US
Practice Address - Phone:508-422-3468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1145741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical