=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861568503
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARJORIE PETERSON LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2006
-----------------------------------------------------
Last Update Date | 06/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6 TODS DRIFTWAY
-----------------------------------------------------
City | OLD GREENWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06870-2412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-257-1411
-----------------------------------------------------
Fax | 203-257-1411
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 TODS DRIFTWAY
-----------------------------------------------------
City | OLD GREENWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06870-2412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-257-1411
-----------------------------------------------------
Fax | 203-257-1411
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 03248672006051
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------