Provider Demographics
NPI:1821587775
Name:PETERSON, MATTHEW (CDCA-PEER RECOVERY)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:CDCA-PEER RECOVERY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 MORGAN ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-2348
Mailing Address - Country:US
Mailing Address - Phone:513-834-7063
Mailing Address - Fax:513-873-1567
Practice Address - Street 1:2300 WALL ST STE F
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45212
Practice Address - Country:US
Practice Address - Phone:513-834-7063
Practice Address - Fax:513-873-1567
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.165456175T00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist