Healthcare Provider Details

I. General information

NPI: 1174055438
Provider Name (Legal Business Name): PETERSON PSYCHIATRIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4265 E MAIN ST
AVON IN
46123-9174
US

IV. Provider business mailing address

4265 E MAIN ST
AVON IN
46123-9174
US

V. Phone/Fax

Practice location:
  • Phone: 317-268-6555
  • Fax:
Mailing address:
  • Phone: 317-268-6555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number71006558A
License Number StateIN

VIII. Authorized Official

Name: BROOKE PETERSON
Title or Position: APRN
Credential: APRN
Phone: 317-268-6555