Provider Demographics
NPI:1093879637
Name:PETERSON, RUSSELL HENRY (MS)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:HENRY
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4360 E 278 N
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5892
Mailing Address - Country:US
Mailing Address - Phone:208-359-4775
Mailing Address - Fax:208-356-5461
Practice Address - Street 1:2375 E SUNNYSIDE RD
Practice Address - Street 2:SUITE C
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8280
Practice Address - Country:US
Practice Address - Phone:208-529-5777
Practice Address - Fax:208-529-5778
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-3125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health