Provider Demographics
NPI:1578063921
Name:PETERS, CARLY (RBT)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 HONEYSUCKLE RD STE 4
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1168
Mailing Address - Country:US
Mailing Address - Phone:334-792-5020
Mailing Address - Fax:334-460-8468
Practice Address - Street 1:256 HONEYSUCKLE RD STE 4
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1168
Practice Address - Country:US
Practice Address - Phone:334-792-5020
Practice Address - Fax:334-460-8468
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
17-32160OtherBACB RBT