MEDICARE: ALLAN T. PETERSON PSY. D, MDIV

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		IL
2	103TC0700X	Clinical Psychologist		IL

General Provider Information

NPI Number	:	1346208410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALLAN T. PETERSON PSY. D, MDIV

Provider Business Mailing Address
First Line	:	4610 WINCHESTER AVE
Second Line	:
City	:	LYONS
State	:	IL
Zip	:	60534-1778
Country	:	US
Telephone Number	:	708-447-8129
Fax Number	:

Provider Business Practice Location Address
First Line	:	4300 W IRVING PARK RD
Second Line	:	COUNSELING CENTER
City	:	CHICAGO
State	:	IL
Zip	:	60641-2825
Country	:	US
Telephone Number	:	773-736-1447
Fax Number	:	773-736-6970

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

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	09/11/2025

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