Provider Demographics
NPI:1720284631
Name:PETERS, SHAENA (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:SHAENA
Middle Name:
Last Name:PETERS
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 1:128 EMMONS BLVD
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-2523
Mailing Address - Country:US
Mailing Address - Phone:734-730-9705
Mailing Address - Fax:
Practice Address - Street 1:19401 NORTHLINE RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2277
Practice Address - Country:US
Practice Address - Phone:734-785-7718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010903431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical