Provider Demographics
NPI:1699231472
Name:PETERSON, PAUL WYNN (LAMFT)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:WYNN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5922
Mailing Address - Street 2:
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72714-0922
Mailing Address - Country:US
Mailing Address - Phone:501-260-7324
Mailing Address - Fax:
Practice Address - Street 1:17 FOLKINGHAM LN
Practice Address - Street 2:
Practice Address - City:BELLA VISTA
Practice Address - State:AR
Practice Address - Zip Code:72715-3042
Practice Address - Country:US
Practice Address - Phone:501-260-7324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-16
Last Update Date:2019-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARF1811011106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist