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NPI Code Detail

MEDICARE: MARIANNA PETERSON MSW

MEDICARE: MARIANNA PETERSON MSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101Y00000XCounselor
2101YM0800XMental Health Counselor
31041C0700XClinical Social Worker
4251S00000XCommunity/Behavioral Health Agency

General Provider Information

NPI Number : 1164827366
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARIANNA PETERSON MSW
Provider Business Mailing Address
First Line : 111 HERMAN ST
Second Line :
City : HIGHLAND
State : IL
Zip : 62249-3209
Country : US
Telephone Number : 618-213-3170
Fax Number : 618-493-6390
Provider Business Practice Location Address
First Line : 5601 STATE ST
Second Line :
City : EAST SAINT LOUIS
State : IL
Zip : 62203-1346
Country : US
Telephone Number : 618-213-3170
Fax Number : 618-493-6390
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/30/2014
Last Update Date : 10/30/2014

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