Provider Demographics
NPI:1346208410
Name:PETERSON, ALLAN T (PSY D, MDIV)
Entity type:Individual
Prefix:
First Name:ALLAN
Middle Name:T
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PSY D, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4610 WINCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:IL
Mailing Address - Zip Code:60534-1778
Mailing Address - Country:US
Mailing Address - Phone:708-447-8129
Mailing Address - Fax:
Practice Address - Street 1:4300 W IRVING PARK RD
Practice Address - Street 2:COUNSELING CENTER
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2825
Practice Address - Country:US
Practice Address - Phone:773-736-1447
Practice Address - Fax:773-736-6970
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical