Provider Demographics
NPI:1699983932
Name:DEBRA I.PETERSON PC
Entity type:Organization
Organization Name:DEBRA I.PETERSON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:701-252-5398
Mailing Address - Street 1:PO BOX 874
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58402-0874
Mailing Address - Country:US
Mailing Address - Phone:701-252-5398
Mailing Address - Fax:701-952-5398
Practice Address - Street 1:300 2ND AVE NE
Practice Address - Street 2:SUITE 221
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-3373
Practice Address - Country:US
Practice Address - Phone:701-252-5398
Practice Address - Fax:701-252-5398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1075101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12115Medicaid
NDN711176Medicare PIN