Provider Demographics
NPI:1700256088
Name:PETERSON, DAVID (LPC, NCC, DCC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LPC, NCC, DCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:75494-2015
Mailing Address - Country:US
Mailing Address - Phone:903-975-1575
Mailing Address - Fax:
Practice Address - Street 1:917 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75494-2015
Practice Address - Country:US
Practice Address - Phone:903-975-1575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67536101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional