Provider Demographics
NPI:1154719482
Name:PETERMAN, MICHELE
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:PETERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:
Other - Last Name:ABER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1075 EVANS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1999
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 N 3RD ST STE 300
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-5550
Practice Address - Country:US
Practice Address - Phone:614-487-8758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-09
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS11219305104100000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No251S00000XAgenciesCommunity/Behavioral Health