Provider Demographics
NPI:1811211139
Name:PETERSON, MELISSA ANNE (LICSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9909 CLAYTON RD
Mailing Address - Street 2:SUITE LL2A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-1120
Mailing Address - Country:US
Mailing Address - Phone:314-649-2416
Mailing Address - Fax:
Practice Address - Street 1:9909 CLAYTON RD
Practice Address - Street 2:SUITE LL2A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63124-1120
Practice Address - Country:US
Practice Address - Phone:314-649-2416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-15
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1156401041C0700X
MO20160215111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical