Provider Demographics
NPI:1841324324
Name:PETERSON, SHARON (LCSW)
Entity type:Individual
Prefix:
First Name:SHARON
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 1:1435 LYNDHURST WAY
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-2574
Mailing Address - Country:US
Mailing Address - Phone:410-440-3074
Mailing Address - Fax:
Practice Address - Street 1:2002 MACY DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-6346
Practice Address - Country:US
Practice Address - Phone:410-440-3074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0054781041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD111427OtherJHHC
MDS8030009OtherBLUE CHOICE
MDS6015865Medicare ID - Type UnspecifiedMEDICARE