Provider Demographics
NPI:1942900667
Name:PETERSON, JULIE BLAKE (LMSW)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:BLAKE
Last Name:PETERSON
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 1:2810 PEACHTREE LN
Mailing Address - Street 2:
Mailing Address - City:PANTEGO
Mailing Address - State:TX
Mailing Address - Zip Code:76013-3115
Mailing Address - Country:US
Mailing Address - Phone:817-412-9704
Mailing Address - Fax:
Practice Address - Street 1:2810 PEACHTREE LN
Practice Address - Street 2:
Practice Address - City:PANTEGO
Practice Address - State:TX
Practice Address - Zip Code:76013-3115
Practice Address - Country:US
Practice Address - Phone:817-412-9704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28303104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker