Provider Demographics
NPI:1639296072
Name:PETERSON, JAMES ANDREW (LCSW-R)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:ANDREW
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 973
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-3624
Mailing Address - Country:US
Mailing Address - Phone:518-901-8762
Mailing Address - Fax:
Practice Address - Street 1:732 MADISON AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3302
Practice Address - Country:US
Practice Address - Phone:518-488-8459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR054667-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS99703Medicare UPIN