Provider Demographics
NPI:1689124430
Name:PETERSON, MATTHEW LEIF (LPC)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:LEIF
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 HUNTERS RUN DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75025-4768
Mailing Address - Country:US
Mailing Address - Phone:857-719-2135
Mailing Address - Fax:
Practice Address - Street 1:2512 HUNTERS RUN DR
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75025-4768
Practice Address - Country:US
Practice Address - Phone:857-719-2135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73142101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional