Provider Demographics
NPI:1790835460
Name:PETERS, MICHAEL HOWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:HOWARD
Last Name:PETERS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-1765
Mailing Address - Country:US
Mailing Address - Phone:631-487-5632
Mailing Address - Fax:
Practice Address - Street 1:37 RIVIERA DR
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-1765
Practice Address - Country:US
Practice Address - Phone:631-487-5632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010800103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV73401Medicare ID - Type UnspecifiedPROVIDER NUMBER