Provider Demographics
NPI:1649650060
Name:PETERSON, MONIQUE LOLITA (LICSW)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:LOLITA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:LOLITA
Other - Last Name:FIELDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:4040 MEMORIAL PKWY SW BLDG 1
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35802-4326
Mailing Address - Country:US
Mailing Address - Phone:256-533-1970
Mailing Address - Fax:256-341-0747
Practice Address - Street 1:4040 MEMORIAL PKWY SW BLDG 1
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-4326
Practice Address - Country:US
Practice Address - Phone:256-533-1970
Practice Address - Fax:256-341-0747
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2586G104100000X
AL4292C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL330000014Medicaid