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General NPI Number Information
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NPI Number | 1568892214
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Entity Type | Organization
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Legal Business Name | MARY LORRAINE PETERSEN, CSW PC
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Dates
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Enumeration Date | 11/16/2013
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Last Update Date | 12/06/2013
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Provider Practice Location Address
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Address Line | 705 HILLTOP CT
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City | CORAM
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State | NY
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Zip | 11727-3640
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Country | US
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Telephone | 631-988-9812
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Fax |
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Provider Business Mailing Address
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Address Line | 705 HILLTOP CT
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City | CORAM
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State | NY
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Zip | 11727-3640
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Country | US
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Telephone | 631-988-9812
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. MARY LORRAINE PETERSEN
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Credential | LCSW
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Telephone | 631-988-9812
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | R023294
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License Number State | NY
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