Provider Demographics
NPI:1174018980
Name:THAXTER, PETER JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOHN
Last Name:THAXTER
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 1:8931 QUARRY RD
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-5160
Mailing Address - Country:US
Mailing Address - Phone:703-969-4539
Mailing Address - Fax:
Practice Address - Street 1:510 PRINCESS ANNE ST STE 102
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-6077
Practice Address - Country:US
Practice Address - Phone:540-698-0003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810006004103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent