Provider Demographics
NPI:1780237602
Name:PETERSON, TERESA (LCSW)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1845
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:OK
Mailing Address - Zip Code:74818-1845
Mailing Address - Country:US
Mailing Address - Phone:405-382-4507
Mailing Address - Fax:405-382-5269
Practice Address - Street 1:2010 BOREN BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868-2050
Practice Address - Country:US
Practice Address - Phone:405-382-4507
Practice Address - Fax:405-382-5269
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK67301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical