Provider Demographics
NPI:1518641950
Name:PETERMAN, DERICK
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:
Last Name:PETERMAN
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 1:364 N BLACK RIVER RD
Mailing Address - Street 2:
Mailing Address - City:ONAWAY
Mailing Address - State:MI
Mailing Address - Zip Code:49765-9540
Mailing Address - Country:US
Mailing Address - Phone:989-306-0466
Mailing Address - Fax:
Practice Address - Street 1:1115 E STATE ST
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-2124
Practice Address - Country:US
Practice Address - Phone:231-268-0007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician