Provider Demographics
NPI:1093563769
Name:PETERSON, BENJAMIN BRADLEY
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:BRADLEY
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3521 STANFORD RD APT 308-0312
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4079
Mailing Address - Country:US
Mailing Address - Phone:612-408-9870
Mailing Address - Fax:
Practice Address - Street 1:3521 STANFORD RD APT 308-0312
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4079
Practice Address - Country:US
Practice Address - Phone:612-408-9870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171W00000XOther Service ProvidersContractor