Healthcare Provider Details

I. General information

NPI: 1477153955
Provider Name (Legal Business Name): DR. PETERSON ALCIDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2020
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 ANDERSON ST SE STE 225
MARIETTA GA
30060-1984
US

IV. Provider business mailing address

166 ANDERSON ST SE STE 225
MARIETTA GA
30060-1984
US

V. Phone/Fax

Practice location:
  • Phone: 203-501-6553
  • Fax:
Mailing address:
  • Phone: 203-501-6553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2472E0500X
TaxonomyEEG Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code246QL0900X
TaxonomyLaboratory Management Specialist/Technologist
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code246Y00000X
TaxonomyHealth Information Specialist/Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: