Provider Demographics
NPI:1649797259
Name:PETERSON, BRYAN (MA, LLP)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1098 ANN ARBOR RD W # 2491
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-2129
Mailing Address - Country:US
Mailing Address - Phone:248-560-7561
Mailing Address - Fax:
Practice Address - Street 1:1098 ANN ARBOR RD W # 2491
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-2129
Practice Address - Country:US
Practice Address - Phone:248-560-7561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361007552103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical