=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861577165
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. ROSS D PETERSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1610 LUTHER LN
-----------------------------------------------------
City | PARK RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60068-1243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-795-3166
-----------------------------------------------------
Fax | 847-823-9222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1724 BONITA AVE
-----------------------------------------------------
City | MOUNT PROSPECT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60056-2810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-437-1357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------