Provider Demographics
NPI:1063731305
Name:PETERSON, CHRISTINA (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4728
Mailing Address - Country:US
Mailing Address - Phone:518-435-5116
Mailing Address - Fax:815-550-2406
Practice Address - Street 1:47 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4728
Practice Address - Country:US
Practice Address - Phone:518-435-5116
Practice Address - Fax:815-550-2406
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1175911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical