Provider Demographics
NPI:1306103676
Name:PETERS, WILLIAM HAROLD
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:HAROLD
Last Name:PETERS
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 1:7713 BRILLIANT FOREST ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-5010
Mailing Address - Country:US
Mailing Address - Phone:608-393-0932
Mailing Address - Fax:
Practice Address - Street 1:3680 N RANCHO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3180
Practice Address - Country:US
Practice Address - Phone:702-869-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIP362-9288-0415-00103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1932247442Medicaid