Provider Demographics
NPI:1639336191
Name:PETERS, STEPHANIE L (LCSW)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:PETERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1233
Mailing Address - Country:US
Mailing Address - Phone:203-503-3055
Mailing Address - Fax:203-503-3066
Practice Address - Street 1:400 POPLAR ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-3336
Practice Address - Country:US
Practice Address - Phone:478-787-4266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235918Medicaid