Provider Demographics
NPI:1144385402
Name:PETERS, RYAN KEITH (LPC-MHSP, NCC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:KEITH
Last Name:PETERS
Suffix:
Gender:M
Credentials:LPC-MHSP, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5017 MORNINGSTAR LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1346
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:252 HARRY LANE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4912
Practice Address - Country:US
Practice Address - Phone:865-338-5384
Practice Address - Fax:865-338-5383
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1660101YP2500X
1660101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5441126Medicaid