Provider Demographics
NPI:1770814485
Name:PETERSON, CAROLYN S (MSW)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:S
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2092 S CUSTER RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-1831
Mailing Address - Country:US
Mailing Address - Phone:734-242-8711
Mailing Address - Fax:734-242-3955
Practice Address - Street 1:2092 S CUSTER RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-1831
Practice Address - Country:US
Practice Address - Phone:734-242-8711
Practice Address - Fax:734-242-3955
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801019721104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker