Provider Demographics
NPI:1952081457
Name:PETERSON, MATTHEW (CRPS)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:CRPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11469 OLIVE BLVD # 264
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7108
Mailing Address - Country:US
Mailing Address - Phone:314-200-5851
Mailing Address - Fax:
Practice Address - Street 1:18033 PROMENADE PARK LN APT 112
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-7980
Practice Address - Country:US
Practice Address - Phone:770-598-1852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist