Provider Demographics
NPI:1255475166
Name:PETERSON, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 OLD HARMONY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-4184
Mailing Address - Country:US
Mailing Address - Phone:302-224-6020
Mailing Address - Fax:302-224-6017
Practice Address - Street 1:924 OLD HARMONY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-4184
Practice Address - Country:US
Practice Address - Phone:302-224-6020
Practice Address - Fax:302-224-6017
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB1-000303103TM1800X
FL1-01-0655103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst