Provider Demographics
NPI:1144322132
Name:NASSEFF, PETER ANTHONY (PHD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:ANTHONY
Last Name:NASSEFF
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 1:401 STAGELINE DRIVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016
Mailing Address - Country:US
Mailing Address - Phone:715-531-6760
Mailing Address - Fax:715-531-6761
Practice Address - Street 1:401 STAGELINE DRIVE
Practice Address - Street 2:SUITE 7
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016
Practice Address - Country:US
Practice Address - Phone:715-531-6760
Practice Address - Fax:715-531-6761
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1536057103T00000X
MNLP2079103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI84423Medicare ID - Type Unspecified