Provider Demographics
NPI:1467087494
Name:PETERSEN, JAMES MARTIN (BASW, CCM, CBIST)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MARTIN
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:BASW, CCM, CBIST
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 281
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49461-0281
Mailing Address - Country:US
Mailing Address - Phone:231-893-1462
Mailing Address - Fax:
Practice Address - Street 1:137 HOLTON WHITEHALL RD
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:MI
Practice Address - Zip Code:49461-9543
Practice Address - Country:US
Practice Address - Phone:231-893-1462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802010722104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker