Provider Demographics
NPI:1699985101
Name:PETERSON, RENAE MICHELLE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:RENAE
Middle Name:MICHELLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 W 112TH ST
Mailing Address - Street 2:APT. 5
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026
Mailing Address - Country:US
Mailing Address - Phone:917-319-9053
Mailing Address - Fax:
Practice Address - Street 1:217 E 87TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-3204
Practice Address - Country:US
Practice Address - Phone:212-876-7427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069639104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker