Provider Demographics
NPI:1235656315
Name:BAZILE, PETERSON
Entity Type:Individual
Prefix:
First Name:PETERSON
Middle Name:
Last Name:BAZILE
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 1:111 MIDDLETON RD
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-4000
Mailing Address - Country:US
Mailing Address - Phone:978-739-7638
Mailing Address - Fax:978-774-4814
Practice Address - Street 1:111 MIDDLETON RD
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-4000
Practice Address - Country:US
Practice Address - Phone:978-739-7638
Practice Address - Fax:978-774-4814
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)