Basic Information
| Provider Information | |||||||||
| NPI: | 1003986068 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | MARY | ||||||||
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| Credential: | MSW, ACSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 SAINT CLAIR RIVER DR | ||||||||
| Address2: | |||||||||
| City: | ALGONAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480011802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107944982 | ||||||||
| FaxNumber: | 8107944407 | ||||||||
| Practice Location | |||||||||
| Address1: | 58144 GRATIOT AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107944982 | ||||||||
| FaxNumber: | 8107944407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801080062 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.