Provider Demographics
NPI:1851491526
Name:PETERSEN, JOHN ANTHONY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANTHONY
Last Name:PETERSEN
Suffix:
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 1:208 E ANGELA BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1202
Mailing Address - Country:US
Mailing Address - Phone:574-288-7919
Mailing Address - Fax:574-280-8199
Practice Address - Street 1:922 E WAYNE ST # 205
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3024
Practice Address - Country:US
Practice Address - Phone:574-280-8199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2018-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041594A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200347860AMedicaid