Provider Demographics
NPI:1598117939
Name:PETERSON, MICHELLE DANIELLE (LPC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DANIELLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 HIAWATHA CT
Mailing Address - Street 2:
Mailing Address - City:MIDLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07432-1005
Mailing Address - Country:US
Mailing Address - Phone:856-373-8639
Mailing Address - Fax:
Practice Address - Street 1:27 HIAWATHA CT
Practice Address - Street 2:
Practice Address - City:MIDLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07432-1005
Practice Address - Country:US
Practice Address - Phone:856-373-8639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC005551000101Y00000X
NJ37LC00247400101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)