Provider Demographics
NPI:1164827366
Name:PETERSON, MARIANNA (MSW)
Entity type:Individual
Prefix:
First Name:MARIANNA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 HERMAN ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-3209
Mailing Address - Country:US
Mailing Address - Phone:618-213-3170
Mailing Address - Fax:618-493-6390
Practice Address - Street 1:5601 STATE ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62203-1346
Practice Address - Country:US
Practice Address - Phone:618-213-3170
Practice Address - Fax:618-493-6390
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid