Provider Demographics
NPI:1821422460
Name:PETERMAN, MICHAEL (LPC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:PETERMAN
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 1:2919 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-1625
Mailing Address - Country:US
Mailing Address - Phone:417-782-7966
Mailing Address - Fax:417-624-4558
Practice Address - Street 1:2919 E 4TH ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-1625
Practice Address - Country:US
Practice Address - Phone:417-782-7966
Practice Address - Fax:417-624-4558
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002096101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional