Provider Demographics
NPI:1891778585
Name:PETERS, JOSEPH EDWARD (PHD)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:EDWARD
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:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81002-0568
Mailing Address - Country:US
Mailing Address - Phone:719-545-5211
Mailing Address - Fax:719-542-0746
Practice Address - Street 1:92 AMHERST AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-1627
Practice Address - Country:US
Practice Address - Phone:719-545-5211
Practice Address - Fax:719-545-1962
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO529103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07005291Medicaid
PE92006OtherBCBS
680000555OtherRR MEDICARE
COC92006Medicare PIN