Provider Demographics
NPI:1437731692
Name:PETERSON, BRIAN THOMAS (RN, LP)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:THOMAS
Last Name:PETERSON
Suffix:
Gender:M
Credentials:RN, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 W 86TH ST PH 1
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-3621
Mailing Address - Country:US
Mailing Address - Phone:646-729-5049
Mailing Address - Fax:
Practice Address - Street 1:50 W 86TH ST PH 1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3621
Practice Address - Country:US
Practice Address - Phone:646-729-5049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY547315163W00000X
NY000807102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No163W00000XNursing Service ProvidersRegistered Nurse