Provider Demographics
NPI:1033246129
Name:HADDAD, PETER J (PHD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:J
Last Name:HADDAD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 EVANS ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-4459
Mailing Address - Country:US
Mailing Address - Phone:989-773-2919
Mailing Address - Fax:
Practice Address - Street 1:1905 EVANS ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-4459
Practice Address - Country:US
Practice Address - Phone:989-773-2919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005523103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G34527Medicare ID - Type UnspecifiedLICENSED PSYCHOLOGIST