Provider Demographics
NPI:1750648119
Name:RICHARD-PETERSON, ETHEL MAE
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:MAE
Last Name:RICHARD-PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 CEDARCREST PL
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-5733
Mailing Address - Country:US
Mailing Address - Phone:813-802-5101
Mailing Address - Fax:
Practice Address - Street 1:1235 LAKE POINTE PKWY STE 104
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-4077
Practice Address - Country:US
Practice Address - Phone:844-824-8775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW49761041C0700X
TX655291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical