Healthcare Provider Details

I. General information

NPI: 1285864363
Provider Name (Legal Business Name): JEAN A GLIEDT-PETER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2009
Last Update Date: 07/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 QUINCY ST
RAPID CITY SD
57701-3712
US

IV. Provider business mailing address

1319 12TH ST
RAPID CITY SD
57701-4410
US

V. Phone/Fax

Practice location:
  • Phone: 605-348-6365
  • Fax:
Mailing address:
  • Phone: 605-343-2503
  • Fax: 605-343-2503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC1169
License Number StateSD

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: