Provider Demographics
NPI:1316916554
Name:PETERSON, ROGER L (PHD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1 PHOENIX MILL LN
Mailing Address - Street 2:STE 200
Mailing Address - City:PETERBOROUGH
Mailing Address - State:NH
Mailing Address - Zip Code:03458-1476
Mailing Address - Country:US
Mailing Address - Phone:603-924-7797
Mailing Address - Fax:603-822-2813
Practice Address - Street 1:222 WEST ST STE 29B
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-2458
Practice Address - Country:US
Practice Address - Phone:603-903-3373
Practice Address - Fax:603-357-1185
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHLP286103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30006111Medicaid
R75847Medicare UPIN
NH30006111Medicaid