Provider Demographics
NPI:1679542484
Name:HERGENROETHER, PETER ROBERT (MA)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:ROBERT
Last Name:HERGENROETHER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 CHIEF EDDIE HOFFMAN HWY
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559
Mailing Address - Country:US
Mailing Address - Phone:907-545-0576
Mailing Address - Fax:
Practice Address - Street 1:829 CHIEF EDDIE HOFFMAN HWY
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559
Practice Address - Country:US
Practice Address - Phone:907-545-0576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK707101YP2500X
MI6801012610104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker