Provider Demographics
NPI:1831664523
Name:PETERS, MARISA LOUISE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:LOUISE
Last Name:PETERS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 STEWART AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4785
Mailing Address - Country:US
Mailing Address - Phone:516-380-0532
Mailing Address - Fax:
Practice Address - Street 1:585 STEWART AVE STE 700
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4785
Practice Address - Country:US
Practice Address - Phone:516-380-0532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NY109163104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)