Provider Demographics
NPI:1790708725
Name:PETERSON, FREDERICK L JR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:L
Last Name:PETERSON
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-1125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:627 S EDWIN C MOSES BLVD
Practice Address - Street 2:SUITE K 5TH FLOOR
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45408-1461
Practice Address - Country:US
Practice Address - Phone:937-424-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3738103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHS49383Medicare UPIN