Provider Demographics
NPI:1740325364
Name:PETERS, JAMES RANDALL (LCSW)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:RANDALL
Last Name:PETERS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:J
Other - Middle Name:RANDALL
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16512-0369
Mailing Address - Country:US
Mailing Address - Phone:814-454-4530
Mailing Address - Fax:814-456-2375
Practice Address - Street 1:1202 STATE ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-1914
Practice Address - Country:US
Practice Address - Phone:814-454-4530
Practice Address - Fax:814-456-2375
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0143911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
472500OtherVALUE OPTIONS
PA104836OtherMAGELLAN
PA018917920001Medicaid
PA910493OtherHIGHMARK BCBS
023539OtherVMC BEHAVIORAL HEALTH CAR
023539OtherVMC BEHAVIORAL HEALTH CAR