Basic Information
| Provider Information | |||||||||
| NPI: | 1316916554 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PHOENIX MILL LN | ||||||||
| Address2: | STE 200 | ||||||||
| City: | PETERBOROUGH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034581476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6039247797 | ||||||||
| FaxNumber: | 6038222813 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 WEST ST STE 29B | ||||||||
| Address2: | |||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034312458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6039033373 | ||||||||
| FaxNumber: | 6033571185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 04/21/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP286 | NH | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 30006111 | 05 | NH | MEDICAID |