Healthcare Provider Details

I. General information

NPI: 1992591010
Provider Name (Legal Business Name): CIARA PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HERITAGE DR STE 100
SOUTHGATE MI
48195-3047
US

IV. Provider business mailing address

24561 SAN MARINO APT 203
BROWNSTOWN MI
48134-9515
US

V. Phone/Fax

Practice location:
  • Phone: 734-767-2250
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: