MEDICARE: DESTINY PETERSON PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	6301016731	MI

General Provider Information

NPI Number	:	1154865590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINY PETERSON PHD

Provider Business Mailing Address
First Line	:	100 MICHIGAN ST NE
Second Line	:	MC 845
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-2560
Country	:	US
Telephone Number	:	616-486-6790
Fax Number	:

Provider Business Practice Location Address
First Line	:	25900 GREENFIELD RD STE 100
Second Line	:
City	:	OAK PARK
State	:	MI
Zip	:	48237-1297
Country	:	US
Telephone Number	:	248-788-4300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2016
Last Update Date	:	07/21/2022

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