Provider Demographics
NPI:1649442633
Name:IPPOLITI, PETER JAMES (PHD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:JAMES
Last Name:IPPOLITI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 UNION ST
Mailing Address - Street 2:SUITE 25
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401
Mailing Address - Country:US
Mailing Address - Phone:207-942-5656
Mailing Address - Fax:
Practice Address - Street 1:4 UNION ST
Practice Address - Street 2:SUITE 25
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-942-5656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS917103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM6814Medicare PIN