Provider Demographics
NPI:1154575017
Name:PETERSON, TERRY LYNN (LMSW)
Entity type:Individual
Prefix:MR
First Name:TERRY
Middle Name:LYNN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 S SHEPHERD DR APT 115
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77019-3534
Mailing Address - Country:US
Mailing Address - Phone:713-927-9892
Mailing Address - Fax:281-442-4904
Practice Address - Street 1:1601 S SHEPHERD DR APT 115
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77019-3534
Practice Address - Country:US
Practice Address - Phone:713-927-9892
Practice Address - Fax:281-442-4904
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX52185104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDAD10-14-1927OtherSOLE PROVIDER