Provider Demographics
NPI:1730440306
Name:PETERSON, REBECCA G
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:G
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 WATERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-1547
Mailing Address - Country:US
Mailing Address - Phone:248-863-7735
Mailing Address - Fax:
Practice Address - Street 1:7250 DIXIE HWY STE 200
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-5108
Practice Address - Country:US
Practice Address - Phone:248-861-2909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011049961041C0700X
MI6802086821104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker