Healthcare Provider Details

I. General information

NPI: 1669152054
Provider Name (Legal Business Name): CHRISTIAN PETERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2023
Last Update Date: 07/20/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280 MAIN ST
WORCESTER MA
01603-1861
US

IV. Provider business mailing address

357 GROVE ST APT 1R
WOONSOCKET RI
02895-5304
US

V. Phone/Fax

Practice location:
  • Phone: 508-754-1141
  • Fax:
Mailing address:
  • Phone: 774-239-4014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

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: