Provider Demographics
NPI:1972319770
Name:PETERSON, THOMAS R
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
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 1:400 WEXFORD AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-5681
Mailing Address - Country:US
Mailing Address - Phone:989-631-9570
Mailing Address - Fax:
Practice Address - Street 1:400 WEXFORD AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-5681
Practice Address - Country:US
Practice Address - Phone:989-631-9570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician