Provider Demographics
NPI:1477153955
Name:ALCIDE, PETERSON
Entity Type:Individual
Prefix:DR
First Name:PETERSON
Middle Name:
Last Name:ALCIDE
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 1:166 ANDERSON ST SE STE 225
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1984
Mailing Address - Country:US
Mailing Address - Phone:203-501-6553
Mailing Address - Fax:
Practice Address - Street 1:166 ANDERSON ST SE STE 225
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1984
Practice Address - Country:US
Practice Address - Phone:203-501-6553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246Y00000X, 246QL0900X, 2472E0500X
GA101Y00000X, 101YM0800X, 132700000X, 225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No246Y00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Health Information
No246QL0900XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyLaboratory Management
No2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No132700000XDietary & Nutritional Service ProvidersDietary Manager
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1609415132Medicaid
GA1477153955Medicaid