Provider Demographics
NPI:1033295712
Name:PETERSON, F TOM (EDD LICENSE PSYCHOLO)
Entity Type:Individual
Prefix:DR
First Name:F
Middle Name:TOM
Last Name:PETERSON
Suffix:
Gender:M
Credentials:EDD LICENSE PSYCHOLO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 176
Mailing Address - Street 2:PETERSON PSYCHOLOGICAL SERVICES
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301-0176
Mailing Address - Country:US
Mailing Address - Phone:406-232-1595
Mailing Address - Fax:406-232-1595
Practice Address - Street 1:18 N 8TH STREET
Practice Address - Street 2:#3
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301-0176
Practice Address - Country:US
Practice Address - Phone:406-232-1595
Practice Address - Fax:406-232-1595
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT119103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT493389Medicaid
MT5053OtherBLUE SHIELD/BC
MT000005442Medicare ID - Type Unspecified