Provider Demographics
NPI:1235549486
Name:PETERS, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
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 1:4000 N DIXIE HWY
Mailing Address - Street 2:SUITE 6
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-4649
Mailing Address - Country:US
Mailing Address - Phone:270-853-3863
Mailing Address - Fax:
Practice Address - Street 1:4000 N DIXIE HWY
Practice Address - Street 2:SUITE 6
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-4649
Practice Address - Country:US
Practice Address - Phone:270-853-3863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY11-03106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist