Provider Demographics
NPI:1376661272
Name:PETERSON, JAMES S (PHD ABPN)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:S
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHD ABPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 583
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903
Mailing Address - Country:US
Mailing Address - Phone:618-529-2227
Mailing Address - Fax:
Practice Address - Street 1:1400 W MAIN
Practice Address - Street 2:SUITE 16
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901
Practice Address - Country:US
Practice Address - Phone:618-529-2227
Practice Address - Fax:618-529-2227
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
556080Medicare ID - Type Unspecified