Provider Demographics
NPI:1629058904
Name:PETERSON, GAIL (PHD)
Entity Type:Individual
Prefix:DR
First Name:GAIL
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 443
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903-0443
Mailing Address - Country:US
Mailing Address - Phone:618-529-4988
Mailing Address - Fax:618-351-1419
Practice Address - Street 1:1400 N WOOD RD
Practice Address - Street 2:MILWOOD EXECUTIVE SUITES
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-6290
Practice Address - Country:US
Practice Address - Phone:618-529-4988
Practice Address - Fax:618-351-1419
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-002561103TB0200X
MO2006006592103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL27485OtherHEALTH ALLIANCE MEDICAL PLANS
IL03972011OtherBLUE CROSS/ BLUE SHIELD
IL126480OtherHEALTHLINK PROVIDER #