Provider Demographics
NPI:1528134848
Name:PETERSON, NATHAN Y (LMHC)
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:Y
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 WHITINS RD
Mailing Address - Street 2:
Mailing Address - City:SUTTON
Mailing Address - State:MA
Mailing Address - Zip Code:01590-2728
Mailing Address - Country:US
Mailing Address - Phone:508-770-0511
Mailing Address - Fax:508-770-0875
Practice Address - Street 1:172 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3750
Practice Address - Country:US
Practice Address - Phone:508-770-0511
Practice Address - Fax:508-770-0875
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4378101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMA4378OtherBCBSMA