Provider Demographics
NPI:1790838159
Name:PETERSON, JULIE ANN (LCSW)
Entity Type:Individual
Prefix:PROF
First Name:JULIE
Middle Name:ANN
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 1:28 WINTER ST
Mailing Address - Street 2:UNIT 2
Mailing Address - City:NORWAY
Mailing Address - State:ME
Mailing Address - Zip Code:04268-5620
Mailing Address - Country:US
Mailing Address - Phone:207-890-8779
Mailing Address - Fax:207-739-2423
Practice Address - Street 1:28 WINTER ST
Practice Address - Street 2:UNIT 2
Practice Address - City:NORWAY
Practice Address - State:ME
Practice Address - Zip Code:04268-5620
Practice Address - Country:US
Practice Address - Phone:207-890-8779
Practice Address - Fax:207-739-2423
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC81641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME276110000Medicaid
ME205225180OtherTRICARE
ME098465OtherANTHEM BC BS
ME11328070OtherCAQH
MEPE MM9928Medicare ID - Type Unspecified