Healthcare Provider Details

I. General information

NPI: 1538089628
Provider Name (Legal Business Name): BRANDON N PETERSON LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 WILLOW BACK RD
SANTA FE NM
87508-1484
US

IV. Provider business mailing address

39 WILLOW BACK RD
SANTA FE NM
87508-1484
US

V. Phone/Fax

Practice location:
  • Phone: 973-572-7961
  • Fax:
Mailing address:
  • Phone: 973-572-7961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2026-0602
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: