Healthcare Provider Details

I. General information

NPI: 1285481531
Provider Name (Legal Business Name): CASEY H PETERSON MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2024
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 FARLOW AVE
RAPID CITY SD
57701-1112
US

IV. Provider business mailing address

PO BOX 2874
RAPID CITY SD
57709-2874
US

V. Phone/Fax

Practice location:
  • Phone: 605-877-1708
  • Fax:
Mailing address:
  • Phone: 605-646-3364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: