Basic Information
| Provider Information | |||||||||
| NPI: | 1053926766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ASW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 GRAVENSTEIN HWY N | ||||||||
| Address2: | |||||||||
| City: | SEBASTOPOL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954722607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7076349050 | ||||||||
| FaxNumber: | 7078233410 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 GRAVENSTEIN HWY N | ||||||||
| Address2: | |||||||||
| City: | SEBASTOPOL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954722607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7076349050 | ||||||||
| FaxNumber: | 7078233410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2020 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ASW94291 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.