Provider Demographics
NPI:1235642760
Name:PETERSON, THOMAS MICHAEL (MS, LPCA, NCC, CCMHC)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MICHAEL
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MS, LPCA, NCC, CCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7919 ANGELICA LN APT 204
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-3088
Mailing Address - Country:US
Mailing Address - Phone:732-233-6777
Mailing Address - Fax:
Practice Address - Street 1:415 E 4TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2405
Practice Address - Country:US
Practice Address - Phone:704-377-5042
Practice Address - Fax:704-377-5043
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13471101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health