Provider Demographics
NPI:1710437918
Name:PETERSON, BRAD EDWARD (MSW)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:EDWARD
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 CROSS RDG
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-4340
Mailing Address - Country:US
Mailing Address - Phone:864-497-3766
Mailing Address - Fax:
Practice Address - Street 1:250 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3009
Practice Address - Country:US
Practice Address - Phone:864-585-0366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health