Provider Demographics
NPI:1033180849
Name:NORDSTROM, PETER DOUGLAS (LMHC)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:DOUGLAS
Last Name:NORDSTROM
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 ABACO DR
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4757
Mailing Address - Country:US
Mailing Address - Phone:352-253-6300
Mailing Address - Fax:352-343-7691
Practice Address - Street 1:114 ST CLAIR ABRAMS AVE
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778
Practice Address - Country:US
Practice Address - Phone:352-253-6300
Practice Address - Fax:352-343-7691
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6961101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ003AOtherBLUE CROSS BLUE SHIELD