Healthcare Provider Details

I. General information

NPI: 1518254770
Provider Name (Legal Business Name): DIANE PETERSON MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9352 EWERS DR
SAINT LOUIS MO
63126-2616
US

IV. Provider business mailing address

9352 EWERS DR
SAINT LOUIS MO
63126-2616
US

V. Phone/Fax

Practice location:
  • Phone: 314-223-2244
  • Fax: 314-722-3515
Mailing address:
  • Phone: 314-223-2244
  • Fax: 314-722-3515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: