Provider Demographics
NPI:1992146427
Name:PETERSON, MICHELLE (PHD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:943 MONTAGUE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-1015
Mailing Address - Country:US
Mailing Address - Phone:803-629-8632
Mailing Address - Fax:
Practice Address - Street 1:1816 BULL ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2506
Practice Address - Country:US
Practice Address - Phone:803-422-0017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1271103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical