Provider Demographics
NPI:1215321187
Name:PETERSON, FRITZ CHARLES (CDP(T))
Entity type:Individual
Prefix:
First Name:FRITZ
Middle Name:CHARLES
Last Name:PETERSON
Suffix:
Gender:M
Credentials:CDP(T)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 PETERSON RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-2606
Mailing Address - Country:US
Mailing Address - Phone:360-757-0131
Mailing Address - Fax:360-757-0136
Practice Address - Street 1:614 PETERSON RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233-2606
Practice Address - Country:US
Practice Address - Phone:360-757-0131
Practice Address - Fax:360-757-0136
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60521386101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACO60521386OtherCHEMICAL DEPENDENCY PROFESSIONAL (TRAINEE)