Provider Demographics
NPI:1104254515
Name:TENENBAUM, PETER DAVID (MSW, LICSW)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:DAVID
Last Name:TENENBAUM
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 RAYMOND CIRCLE
Mailing Address - Street 2:
Mailing Address - City:WHITE RIVER JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05001
Mailing Address - Country:US
Mailing Address - Phone:802-291-1789
Mailing Address - Fax:
Practice Address - Street 1:67 RAYMOND CIRCLE
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001
Practice Address - Country:US
Practice Address - Phone:802-291-1789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-22
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.0000242104100000X
NH1112104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker