=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518335967
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER NELSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2015
-----------------------------------------------------
Last Update Date | 02/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 367 SHAKER RD
-----------------------------------------------------
City | CANTERBURY
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03224-2714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 774-893-3253
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21B NORMAN DR
-----------------------------------------------------
City | DERRY
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03038-7241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 774-893-3253
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 1200
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------