Provider Demographics
NPI:1881900967
Name:PETERSEN, RONALD D
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:D
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LIMERICK
Mailing Address - State:ME
Mailing Address - Zip Code:04048-3502
Mailing Address - Country:US
Mailing Address - Phone:207-793-4673
Mailing Address - Fax:
Practice Address - Street 1:143 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:LIMERICK
Practice Address - State:ME
Practice Address - Zip Code:04048-3502
Practice Address - Country:US
Practice Address - Phone:207-793-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME606510101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral