Provider Demographics
NPI:1184396608
Name:PETERSEN, CARLEIGH
Entity type:Individual
Prefix:
First Name:CARLEIGH
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27B BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER BY THE SEA
Mailing Address - State:MA
Mailing Address - Zip Code:01944-1410
Mailing Address - Country:US
Mailing Address - Phone:818-326-6754
Mailing Address - Fax:
Practice Address - Street 1:27B BRIDGE ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER BY THE SEA
Practice Address - State:MA
Practice Address - Zip Code:01944-1410
Practice Address - Country:US
Practice Address - Phone:818-326-6754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-03
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-25-79070103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst