Provider Demographics
NPI:1649153677
Name:PETERSON, CAROLINE ELIABETH
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:ELIABETH
Last Name:PETERSON
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 1:132 ARUBA AVE
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-6107
Mailing Address - Country:US
Mailing Address - Phone:912-658-5350
Mailing Address - Fax:
Practice Address - Street 1:132 ARUBA AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-6107
Practice Address - Country:US
Practice Address - Phone:912-658-5350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-28
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst