Provider Demographics
NPI:1124375472
Name:PETERS, GEORGE EDWARD III
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:EDWARD
Last Name:PETERS
Suffix:III
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 1:14424 TIMBERDALE DR
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-8311
Mailing Address - Country:US
Mailing Address - Phone:405-314-4891
Mailing Address - Fax:
Practice Address - Street 1:14424 TIMBERDALE DR
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-8311
Practice Address - Country:US
Practice Address - Phone:405-314-4891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor