Healthcare Provider Details

I. General information

NPI: 1710302815
Provider Name (Legal Business Name): MARTINIQUE MICHELLE PETERS MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARTI M PETERS MA

II. Dates (important events)

Enumeration Date: 02/26/2014
Last Update Date: 03/21/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 ARBOR DRIVE
SOUTH SIOUX CITY NE
68776-2652
US

IV. Provider business mailing address

1201 ARBOR DRIVE PO BOX 355
SOUTH SIOUX CITY NE
68776-2652
US

V. Phone/Fax

Practice location:
  • Phone: 402-494-3337
  • Fax: 402-494-3356
Mailing address:
  • Phone: 402-494-3337
  • Fax: 402-494-3356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberP-1200
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10285
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: