Provider Demographics
NPI:1699204602
Name:PETERSON, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8788 RED PINE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ANN
Mailing Address - State:MI
Mailing Address - Zip Code:49650-9708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1363 DOUGLAS DR STE 104
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49696-8980
Practice Address - Country:US
Practice Address - Phone:231-668-4909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician