Provider Demographics
NPI:1699280479
Name:PETTERSON, CAROLYN MARIE (AAC)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:MARIE
Last Name:PETTERSON
Suffix:
Gender:F
Credentials:AAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:MAHANOY CITY
Mailing Address - State:PA
Mailing Address - Zip Code:17948-2515
Mailing Address - Country:US
Mailing Address - Phone:570-875-7622
Mailing Address - Fax:570-462-1042
Practice Address - Street 1:1 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:PA
Practice Address - Zip Code:17976-2332
Practice Address - Country:US
Practice Address - Phone:570-462-1040
Practice Address - Fax:570-462-1040
Is Sole Proprietor?:No
Enumeration Date:2017-12-03
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA10447101Y00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor