Provider Demographics
NPI:1861688608
Name:PETERSON, RYAN W (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:W
Last Name:PETERSON
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 1:115 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:NY
Mailing Address - Zip Code:14810-1508
Mailing Address - Country:US
Mailing Address - Phone:607-776-6577
Mailing Address - Fax:607-664-2161
Practice Address - Street 1:115 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-1508
Practice Address - Country:US
Practice Address - Phone:607-776-6577
Practice Address - Fax:607-664-2161
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NY019091-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health