Provider Demographics
NPI:1427469519
Name:PETERSON, CHANTAL MARIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:CHANTAL
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:CHANTAL
Other - Middle Name:
Other - Last Name:CAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1770 RAND RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-9347
Mailing Address - Country:US
Mailing Address - Phone:605-791-1514
Mailing Address - Fax:844-831-2349
Practice Address - Street 1:1770 RAND RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-9347
Practice Address - Country:US
Practice Address - Phone:605-791-1514
Practice Address - Fax:844-831-2349
Is Sole Proprietor?:No
Enumeration Date:2014-05-12
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD515103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical