Basic Information
| Provider Information | |||||||||
| NPI: | 1023464682 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LISW, CDCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1341 MARKET AVE N | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447142605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304538252 | ||||||||
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| Practice Location | |||||||||
| Address1: | 733 MARKET AVE S | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447022165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304894600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2016 | ||||||||
| LastUpdateDate: | 11/30/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0012311 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 011229 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | I1801316 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 2901131 | 05 | OH | MEDICAID |