Basic Information
Provider Information | |||||||||
NPI: | 1740325364 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PETERS | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | RANDALL | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PETERS | ||||||||
OtherFirstName: | J | ||||||||
OtherMiddleName: | RANDALL | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCSW | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 369 | ||||||||
Address2: |   | ||||||||
City: | ERIE | ||||||||
State: | PA | ||||||||
PostalCode: | 165120369 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8144544530 | ||||||||
FaxNumber: | 8144562375 | ||||||||
Practice Location | |||||||||
Address1: | 1202 STATE ST | ||||||||
Address2: |   | ||||||||
City: | ERIE | ||||||||
State: | PA | ||||||||
PostalCode: | 165011914 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8144544530 | ||||||||
FaxNumber: | 8144562375 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/21/2007 | ||||||||
LastUpdateDate: | 09/13/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CW014391 | PA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 472500 | 01 |   | VALUE OPTIONS | OTHER | 104836 | 01 | PA | MAGELLAN | OTHER | 018917920001 | 05 | PA |   | MEDICAID | 910493 | 01 | PA | HIGHMARK BCBS | OTHER | 023539 | 01 |   | VMC BEHAVIORAL HEALTH CAR | OTHER |