Healthcare Provider Details

I. General information

NPI: 1962760736
Provider Name (Legal Business Name): STACEY PETERS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 VANDENBERG DRIVE BLDG 1900 MHC
HANSCOM AFB MA
01731
US

IV. Provider business mailing address

90 VANDENBERG DRIVE BLDG 1900 MHC
HANSCOM AFB MA
01731
US

V. Phone/Fax

Practice location:
  • Phone: 781-225-6384
  • Fax:
Mailing address:
  • Phone: 781-225-6384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number111990
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: