Provider Demographics
NPI:1316318553
Name:PETERSON, THOMAS C (LPC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:C
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9320 RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-2416
Mailing Address - Country:US
Mailing Address - Phone:662-893-1308
Mailing Address - Fax:662-893-1330
Practice Address - Street 1:423 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39701-5772
Practice Address - Country:US
Practice Address - Phone:662-769-2331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-14
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2123101YM0800X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health