Provider Demographics
NPI:1750838942
Name:PETERSON, SALLY (LCSW)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
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 1:3160 CAMINO DEL RIO S
Mailing Address - Street 2:#304
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3813
Mailing Address - Country:US
Mailing Address - Phone:619-819-0283
Mailing Address - Fax:610-819-0284
Practice Address - Street 1:3160 CAMINO DEL RIO S
Practice Address - Street 2:#304
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3813
Practice Address - Country:US
Practice Address - Phone:619-819-0283
Practice Address - Fax:610-819-0284
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW208651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical