Provider Demographics
NPI:1518010636
Name:PETERSON, ROBERT LEE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11198 GOOSE CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4276
Mailing Address - Country:US
Mailing Address - Phone:307-267-7224
Mailing Address - Fax:
Practice Address - Street 1:11198 GOOSE CREEK CIR
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4276
Practice Address - Country:US
Practice Address - Phone:307-267-7224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2024-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYCSSP-18103T00000X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1023346053Medicaid
WY116545300Medicaid