Provider Demographics
NPI:1659501617
Name:PETERS, FREDERICK JAMES JR
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:JAMES
Last Name:PETERS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:FREDERICK
Other - Middle Name:JAMES
Other - Last Name:PETERS
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:259 N KELLY ST
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-5209
Mailing Address - Country:US
Mailing Address - Phone:704-500-0087
Mailing Address - Fax:704-500-2720
Practice Address - Street 1:259 N KELLY ST
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-5209
Practice Address - Country:US
Practice Address - Phone:704-500-0087
Practice Address - Fax:704-500-2720
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0043771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical