MEDICARE: DR. BRENT C PETERSON PH.D, LPC, ATR,

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	101YP2500X	Professional Counselor	0701004570	VA

General Provider Information

NPI Number	:	1497934400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRENT C PETERSON PH.D, LPC, ATR,

Provider Business Mailing Address
First Line	:	1309 JAMESTOWN RD STE 201
Second Line	:
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23185-3380
Country	:	US
Telephone Number	:	757-284-4554
Fax Number	:	757-500-0134

Provider Business Practice Location Address
First Line	:	1309 JAMESTOWN RD STE 201
Second Line	:
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23185-3380
Country	:	US
Telephone Number	:	757-284-4554
Fax Number	:	757-500-0134

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

Provider Enumeration Date	:	10/25/2007
Last Update Date	:	10/13/2025

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