Basic Information
| Provider Information | |||||||||
| NPI: | 1538505219 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CASAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LANE | ||||||||
| OtherFirstName: | CHRISTINE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | CASAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 227 THORN AVE | ||||||||
| Address2: | |||||||||
| City: | ORCHARD PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166622040 | ||||||||
| FaxNumber: | 7166620019 | ||||||||
| Practice Location | |||||||||
| Address1: | 34 N. MAIN STREET SPECTRUM HEALTH & HUMAN SERVICES | ||||||||
| Address2: | |||||||||
| City: | WARSAW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145691326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857860220 | ||||||||
| FaxNumber: | 5857863631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2013 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 28728 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.