Healthcare Provider Details

I. General information

NPI: 1780237602
Provider Name (Legal Business Name): TERESA PETERSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2019
Last Update Date: 07/31/2023
Certification Date: 09/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 BOREN BLVD
SEMINOLE OK
74868-2050
US

IV. Provider business mailing address

PO BOX 1845
SEMINOLE OK
74818-1845
US

V. Phone/Fax

Practice location:
  • Phone: 405-382-4507
  • Fax: 405-382-5269
Mailing address:
  • Phone: 405-382-4507
  • Fax: 405-382-5269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6730
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: