Provider Demographics
NPI:1245776566
Name:PETTERS, CARMON
Entity Type:Individual
Prefix:
First Name:CARMON
Middle Name:
Last Name:PETTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 14TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51105-1207
Mailing Address - Country:US
Mailing Address - Phone:712-252-7170
Mailing Address - Fax:
Practice Address - Street 1:520 14TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51105-1207
Practice Address - Country:US
Practice Address - Phone:712-252-7170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health