Provider Demographics
NPI:1164589610
Name:PETERSON, GARY ROBERT (MA,LMHC,CEAP,SAP)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:ROBERT
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MA,LMHC,CEAP,SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1538 THE GREENS WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-1400
Mailing Address - Country:US
Mailing Address - Phone:904-543-0161
Mailing Address - Fax:904-543-9172
Practice Address - Street 1:1538 THE GREENS WAY STE 101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-1400
Practice Address - Country:US
Practice Address - Phone:904-543-0161
Practice Address - Fax:904-543-9172
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH0001443101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH0001443OtherLIC MENTAL HEALTH COU