Provider Demographics
NPI:1861675902
Name:PETERSON, MARLENE M (LCSW)
Entity Type:Individual
Prefix:
First Name:MARLENE
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 1:9951 US HIGHWAY 190 E
Mailing Address - Street 2:
Mailing Address - City:POINTBLANK
Mailing Address - State:TX
Mailing Address - Zip Code:77364-6896
Mailing Address - Country:US
Mailing Address - Phone:281-851-1685
Mailing Address - Fax:
Practice Address - Street 1:9951 US HIGHWAY 190 E
Practice Address - Street 2:
Practice Address - City:POINTBLANK
Practice Address - State:TX
Practice Address - Zip Code:77364-6896
Practice Address - Country:US
Practice Address - Phone:281-851-1685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-12
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX124011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX610078Medicare PIN