Provider Demographics
NPI:1861568503
Name:PETERSON, MARJORIE (LCSW)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 TODS DRIFTWAY
Mailing Address - Street 2:
Mailing Address - City:OLD GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06870-2412
Mailing Address - Country:US
Mailing Address - Phone:203-257-1411
Mailing Address - Fax:203-257-1411
Practice Address - Street 1:6 TODS DRIFTWAY
Practice Address - Street 2:
Practice Address - City:OLD GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06870-2412
Practice Address - Country:US
Practice Address - Phone:203-257-1411
Practice Address - Fax:203-257-1411
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT032486720060511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004172912Medicaid
CT004172920Medicare ID - Type Unspecified