Healthcare Provider Details

I. General information

NPI: 1639985880
Provider Name (Legal Business Name): THOMAS PETERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 RIDGECREST RD SE APT 8
GRAND RAPIDS MI
49546-4366
US

IV. Provider business mailing address

2151 RIDGECREST RD SE APT 8
GRAND RAPIDS MI
49546-4366
US

V. Phone/Fax

Practice location:
  • Phone: 502-439-7039
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number270750
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401224433
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: