Provider Demographics
NPI:1659555092
Name:PETERSON, MICHAEL (LLC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2540 FLOWOOD DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232
Mailing Address - Country:US
Mailing Address - Phone:601-939-5993
Mailing Address - Fax:
Practice Address - Street 1:2540 FLOWOOD DR
Practice Address - Street 2:SUITE A
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9362
Practice Address - Country:US
Practice Address - Phone:601-939-5993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional