Provider Demographics
NPI:1972234821
Name:PETERSON, TYRONE
Entity Type:Individual
Prefix:
First Name:TYRONE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W HIGHLAND RD STE 102
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48357-4573
Mailing Address - Country:US
Mailing Address - Phone:248-529-3167
Mailing Address - Fax:810-215-1135
Practice Address - Street 1:210 W HIGHLAND RD STE 102
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:MI
Practice Address - Zip Code:48357-4573
Practice Address - Country:US
Practice Address - Phone:248-529-3167
Practice Address - Fax:810-215-1135
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511147651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical