Healthcare Provider Details

I. General information

NPI: 1144618521
Provider Name (Legal Business Name): MARCY LYNN PETERS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2015
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

698 N MINERAL WELLS AVE
MERIDIAN ID
83642-7610
US

IV. Provider business mailing address

698 N MINERAL WELLS AVE
MERIDIAN ID
83642-7610
US

V. Phone/Fax

Practice location:
  • Phone: 661-674-7104
  • Fax:
Mailing address:
  • Phone: 661-674-7104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberCFH-10581
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8861122
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: