Provider Demographics
NPI:1114471687
Name:PETERS, STEVEN THOMAS
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:THOMAS
Last Name:PETERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 E BROWN RD
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48744-9503
Mailing Address - Country:US
Mailing Address - Phone:810-728-8043
Mailing Address - Fax:
Practice Address - Street 1:651 N STATE ST
Practice Address - Street 2:
Practice Address - City:CARO
Practice Address - State:MI
Practice Address - Zip Code:48723-1543
Practice Address - Country:US
Practice Address - Phone:989-673-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-12
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015994390200000X
MI6301017202103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty