Provider Demographics
NPI:1114130465
Name:PETERSON, GARY GLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:GLEN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHD
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 3441
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83353-3441
Mailing Address - Country:US
Mailing Address - Phone:208-928-6555
Mailing Address - Fax:208-928-7666
Practice Address - Street 1:675 SUN VALLEY ROAD
Practice Address - Street 2:C
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-928-6555
Practice Address - Fax:208-928-7666
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7790103T00000X
IDPSY 202479103T00000X
AZ578103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist