Healthcare Provider Details

I. General information

NPI: 1730890401
Provider Name (Legal Business Name): DEREK PETERSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2022
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 SPRINGDALE DR
EXTON PA
19341-2843
US

IV. Provider business mailing address

825 SPRINGDALE DR
EXTON PA
19341-2843
US

V. Phone/Fax

Practice location:
  • Phone: 888-227-3898
  • Fax:
Mailing address:
  • Phone: 888-227-3898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: