Provider Demographics
NPI:1104046739
Name:DESMANGLES, PETER RICHARD (MS, LMHC, LCAC)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:RICHARD
Last Name:DESMANGLES
Suffix:
Gender:M
Credentials:MS, LMHC, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 EXECUTIVE DR STE G
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4875
Mailing Address - Country:US
Mailing Address - Phone:653-377-7577
Mailing Address - Fax:765-446-0010
Practice Address - Street 1:114 EXECUTIVE DR STE G
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4875
Practice Address - Country:US
Practice Address - Phone:765-337-7757
Practice Address - Fax:765-446-0010
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001705A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health