Provider Demographics
NPI:1346960259
Name:PETER, SAMUEL CODY (PHD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:CODY
Last Name:PETER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-3119
Mailing Address - Country:US
Mailing Address - Phone:618-979-1186
Mailing Address - Fax:
Practice Address - Street 1:1830 HILLANDALE RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2670
Practice Address - Country:US
Practice Address - Phone:919-286-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6196103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical