Basic Information
| Provider Information | |||||||||
| NPI: | 1326179466 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | J | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17800 US HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923071221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609468200 | ||||||||
| FaxNumber: | 7609468208 | ||||||||
| Practice Location | |||||||||
| Address1: | 17800 US HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923071221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609468200 | ||||||||
| FaxNumber: | 7609468208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 05/07/2018 | ||||||||
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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 | 101YM0800X | 43011 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | 87914 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 43011 | 01 | CA | IMF | OTHER |