Provider Demographics
NPI:1326179466
Name:PETERSON, EDWARD J
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:PETERSON
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 1:17800 US HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-1221
Mailing Address - Country:US
Mailing Address - Phone:760-946-8200
Mailing Address - Fax:760-946-8208
Practice Address - Street 1:17800 US HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1221
Practice Address - Country:US
Practice Address - Phone:760-946-8200
Practice Address - Fax:760-946-8208
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43011101YM0800X
CA87914106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA43011OtherIMF