Basic Information
Provider Information | |||||||||
NPI: | 1356318737 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NANCY C. PETERS, PH.D. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2450 DELANEY RD | ||||||||
Address2: |   | ||||||||
City: | WILMINGTON | ||||||||
State: | NC | ||||||||
PostalCode: | 284036062 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9107629083 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2450 DELANEY RD | ||||||||
Address2: |   | ||||||||
City: | WILMINGTON | ||||||||
State: | NC | ||||||||
PostalCode: | 284036062 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9107629083 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/03/2006 | ||||||||
LastUpdateDate: | 10/19/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PETERS | ||||||||
AuthorizedOfficialFirstName: | NANCY | ||||||||
AuthorizedOfficialMiddleName: | C. | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9107629083 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PH.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 0438 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | 04360 | 01 |   | BLUE CROSS/BLUE SHIELD | OTHER | 70180 | 01 |   | MEDCOST | OTHER | 071991 | 01 |   | VALUE OPTIONS | OTHER | 61-07217 | 01 |   | UBH | OTHER | 7266127 | 01 |   | AETNA | OTHER | 6000101 | 05 | NC |   | MEDICAID | 900012686 | 01 |   | PRIORITY HEALTH | OTHER | IPO39303 | 01 |   | MAGELLAN | OTHER |