Provider Demographics
NPI:1821314774
Name:PETERSON, STACY M (LCSW)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:M
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 1:1300 GOLDEN GATE AVE
Mailing Address - Street 2:APT #408
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-4760
Mailing Address - Country:US
Mailing Address - Phone:415-830-0679
Mailing Address - Fax:
Practice Address - Street 1:405 CLEMENT ST
Practice Address - Street 2:SUITE #2
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-2317
Practice Address - Country:US
Practice Address - Phone:415-830-0679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-18
Last Update Date:2010-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA233871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical