=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003470436
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID PETERS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2019
-----------------------------------------------------
Last Update Date | 05/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 720 EAST ALICE
-----------------------------------------------------
City | BLACKFOOT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-782-9874
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 129
-----------------------------------------------------
City | BLACKFOOT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83221-0129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-782-9874
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | LMFT-2978
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------