Provider Demographics
NPI:1053926766
Name:PETERSON, MARY (ASW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 GRAVENSTEIN HWY N
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-2607
Mailing Address - Country:US
Mailing Address - Phone:707-634-9050
Mailing Address - Fax:707-823-3410
Practice Address - Street 1:1800 GRAVENSTEIN HWY N
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-2607
Practice Address - Country:US
Practice Address - Phone:707-634-9050
Practice Address - Fax:707-823-3410
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW94291101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health