Basic Information
| Provider Information | |||||||||
| NPI: | 1841765732 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | MARISSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 232 E 82ND ST | ||||||||
| Address2: | |||||||||
| City: | NEWAYGO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493379631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316521780 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2723 S STATE ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481046188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8442631613 | ||||||||
| FaxNumber: | 8442631612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2018 | ||||||||
| LastUpdateDate: | 08/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.