Doctor Name: | THOMAS PETERSON |
NPI Number: | 1316318553 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | |
License Number: | |
Business Practice Address: | 9320 Railroad Ave Olive Branch, MS - 386542416 |
Business Phone Number: | 6628931308 |
Business Fax Number: | 6628931330 |
Mailing Address: | 9320 Railroad Ave, OLIVE BRANCH |
State: | MS |
Postal Code: | 386542416 |
Phone Number: | 6628931308 |
Fax Number: | 6628931330 |
NPI Enumeration Date: | 10/14/2015 |
NPI Last Update Date: | 10/14/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YA0400X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Addiction (Substance Use Disorder) |
Taxonomy Definition: |