Healthcare Provider Details

I. General information

NPI: 1619766003
Provider Name (Legal Business Name): MARIA C PETERSON PCMHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2025
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 BROAD AVE
GULFPORT MS
39501-3603
US

IV. Provider business mailing address

1600 BROAD AVE
GULFPORT MS
39501-3603
US

V. Phone/Fax

Practice location:
  • Phone: 228-213-5888
  • Fax: 228-575-3433
Mailing address:
  • Phone: 228-213-5888
  • Fax: 228-575-3433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6834
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: