Provider Demographics
NPI:1023263563
Name:PETERSON, MARY (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1717 BIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63106-3454
Mailing Address - Country:US
Mailing Address - Phone:314-814-8628
Mailing Address - Fax:314-814-8542
Practice Address - Street 1:100 N TUCKER BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101-1931
Practice Address - Country:US
Practice Address - Phone:314-814-8628
Practice Address - Fax:314-814-8542
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030262241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical