Provider Demographics
NPI:1912257130
Name:PETERSON, STEPHANIE MARIE (PHD, BCBA-D)
Entity Type:Individual
Prefix:PROF
First Name:STEPHANIE
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11583 S. 8TH ST.
Mailing Address - Street 2:
Mailing Address - City:SCHOOLCRAFT
Mailing Address - State:MI
Mailing Address - Zip Code:49087
Mailing Address - Country:US
Mailing Address - Phone:435-213-0726
Mailing Address - Fax:
Practice Address - Street 1:11583 S. 8TH ST.
Practice Address - Street 2:
Practice Address - City:SCHOOLCRAFT
Practice Address - State:MI
Practice Address - Zip Code:49087
Practice Address - Country:US
Practice Address - Phone:435-213-0726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-01-0656103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst