Provider Demographics
NPI:1922721885
Name:PETERSON, MICHAEL ALLEN (LCDCI)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALLEN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LCDCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8444 N 90TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4437
Mailing Address - Country:US
Mailing Address - Phone:602-248-8886
Mailing Address - Fax:480-687-7361
Practice Address - Street 1:405 N MCDONALD ST STE B
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75069-3911
Practice Address - Country:US
Practice Address - Phone:972-542-4144
Practice Address - Fax:480-687-7361
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX58858101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)