Healthcare Provider Details

I. General information

NPI: 1770487753
Provider Name (Legal Business Name): MARY PETERSON
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 N DETROIT ST
WEST LIBERTY OH
43357-9805
US

IV. Provider business mailing address

5982 RHODES RD
KENT OH
44240-8100
US

V. Phone/Fax

Practice location:
  • Phone: 330-673-1347
  • Fax: 326-529-4070
Mailing address:
  • Phone:
  • Fax: 330-678-3677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: