Provider Demographics
NPI:1588189039
Name:PETERS, MICHAEL JOSEPH SR (CADC 1670AD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:PETERS
Suffix:SR
Gender:M
Credentials:CADC 1670AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 MALDEN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-1006
Mailing Address - Country:US
Mailing Address - Phone:1508-853-4391
Mailing Address - Fax:
Practice Address - Street 1:56 MALDEN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606
Practice Address - Country:US
Practice Address - Phone:1508-853-4391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-06
Last Update Date:2017-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1670AD101YA0400X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)