Provider Demographics
NPI:1871230581
Name:PETERSON-SMITH, DEBRA GRACE (LMHC)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:GRACE
Last Name:PETERSON-SMITH
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7652 STATE ROUTE 31
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:13030-8400
Mailing Address - Country:US
Mailing Address - Phone:315-247-0816
Mailing Address - Fax:
Practice Address - Street 1:7652 STATE ROUTE 31
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:NY
Practice Address - Zip Code:13030-8400
Practice Address - Country:US
Practice Address - Phone:315-247-0816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-14
Last Update Date:2022-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000946101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health