Basic Information
| Provider Information | |||||||||
| NPI: | 1962636803 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERS | ||||||||
| FirstName: | BRANDEN | ||||||||
| MiddleName: | D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 BERING | ||||||||
| Address2: | SUITE 940 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819211818 | ||||||||
| FaxNumber: | 2819211919 | ||||||||
| Practice Location | |||||||||
| Address1: | 9100 SOUTHWEST FWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770741519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134574372 | ||||||||
| FaxNumber: | 7134570945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2009 | ||||||||
| LastUpdateDate: | 08/27/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 62669 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 62669 | 05 | TX | MEDICAID |