1023263563 NPI number — MARY PETERSON LCSW

Table of content: MARY PETERSON LCSW (NPI 1023263563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023263563 NPI number — MARY PETERSON LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
MARY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETERSON
Provider Other First Name:
MARY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1023263563
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1717 BIDDLE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63106-3454
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-814-8628
Provider Business Mailing Address Fax Number:
314-814-8542

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N TUCKER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63101-1931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-814-8628
Provider Business Practice Location Address Fax Number:
314-814-8542
Provider Enumeration Date:
11/25/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  2003026224 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)