Provider Demographics
NPI:1750550356
Name:PETERSON, MARY JOAN (LICSW)
Entity type:Individual
Prefix:MS
First Name:MARY JOAN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 BUTLER AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:MAYNARD
Mailing Address - State:MA
Mailing Address - Zip Code:01754-1403
Mailing Address - Country:US
Mailing Address - Phone:617-877-8108
Mailing Address - Fax:
Practice Address - Street 1:24 BARTLEY ST
Practice Address - Street 2:#4
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-3138
Practice Address - Country:US
Practice Address - Phone:617-877-8108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-27
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1133821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO1212Medicare PIN