Provider Demographics
NPI:1558656728
Name:PETERS, LIVINIUS CHARLES (BHRS)
Entity Type:Individual
Prefix:
First Name:LIVINIUS
Middle Name:CHARLES
Last Name:PETERS
Suffix:
Gender:M
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 FOXFIRE RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-6202
Mailing Address - Country:US
Mailing Address - Phone:405-509-1180
Mailing Address - Fax:
Practice Address - Street 1:1609 GREENBRIAR PL
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7640
Practice Address - Country:US
Practice Address - Phone:405-735-3683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200033660Medicaid