Provider Demographics
NPI:1043976483
Name:PETERSEN, MARIAH ANNE (BCBA)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:ANNE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:ANNE
Other - Last Name:EUBANK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:
Practice Address - Street 1:815 S DONAGHEY AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-6880
Practice Address - Country:US
Practice Address - Phone:501-400-0924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-10
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARRBT-21-179641106S00000X
AR103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician