Basic Information
| Provider Information | |||||||||
| NPI: | 1922721885 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | LCDCI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8444 N 90TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852584437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022488886 | ||||||||
| FaxNumber: | 4806877361 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 N MCDONALD ST STE B | ||||||||
| Address2: | |||||||||
| City: | MCKINNEY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750693911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725424144 | ||||||||
| FaxNumber: | 4806877361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2022 | ||||||||
| LastUpdateDate: | 09/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 58858 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.