Provider Demographics
NPI:1023464682
Name:PETERSON, JOHN (LISW, CDCA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LISW, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1341 MARKET AVE N
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44714-2605
Mailing Address - Country:US
Mailing Address - Phone:330-453-8252
Mailing Address - Fax:
Practice Address - Street 1:733 MARKET AVE S
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44702-2165
Practice Address - Country:US
Practice Address - Phone:330-489-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0012311101YA0400X
OH011229101YA0400X
OHI18013161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2901131Medicaid