=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174018980
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER JOHN THAXTER PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2018
-----------------------------------------------------
Last Update Date | 06/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 510 PRINCESS ANNE ST STE 102
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22401-6077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-698-0003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8931 QUARRY RD
-----------------------------------------------------
City | MANASSAS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20110-5160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-969-4539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 0810006004
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------