Provider Demographics
NPI:1962833897
Name:WADSWORTH, PETER J (BA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:WADSWORTH
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2588 E 98TH N
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5475
Mailing Address - Country:US
Mailing Address - Phone:208-390-5858
Mailing Address - Fax:208-552-9999
Practice Address - Street 1:2588 E 98TH N
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5475
Practice Address - Country:US
Practice Address - Phone:208-390-5858
Practice Address - Fax:208-552-9999
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst