Provider Demographics
NPI:1427325265
Name:PETERSON, THEADORA RUTH (LADC-1)
Entity type:Individual
Prefix:MISS
First Name:THEADORA
Middle Name:RUTH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LADC-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 MEETING HOUSE HILL RD
Mailing Address - Street 2:
Mailing Address - City:WEST NEWBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01985-1509
Mailing Address - Country:US
Mailing Address - Phone:617-447-4043
Mailing Address - Fax:
Practice Address - Street 1:8 HARRIS ST
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-2635
Practice Address - Country:US
Practice Address - Phone:617-447-4043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-22
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA22506101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health