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General NPI Number Information
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NPI Number | 1174055438
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Entity Type | Organization
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Legal Business Name | PETERSON PSYCHIATRIC SERVICES, LLC
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Dates
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Enumeration Date | 03/28/2017
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Last Update Date | 03/28/2017
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Provider Practice Location Address
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Address Line | 4265 E MAIN ST
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City | AVON
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State | IN
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Zip | 46123-9174
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Country | US
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Telephone | 317-268-6555
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Fax |
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Provider Business Mailing Address
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Address Line | 4265 E MAIN ST
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City | AVON
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State | IN
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Zip | 46123-9174
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Country | US
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Telephone | 317-268-6555
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Fax |
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Authorized Official
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Title or Position | APRN
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Name | BROOKE PETERSON
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Credential | APRN
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Telephone | 317-268-6555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WP0808X
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Taxonomy Name | Psychiatric/Mental Health Registered Nurse
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License Number | 71006558A
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License Number State | IN
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