Provider Demographics
NPI:1538184395
Name:PETERSON, JOHN H (MS)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:H
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1478 KENWOOD CTR
Mailing Address - Street 2:SUITE #1
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1161
Mailing Address - Country:US
Mailing Address - Phone:920-886-9319
Mailing Address - Fax:920-886-9357
Practice Address - Street 1:1478 KENWOOD CTR
Practice Address - Street 2:SUITE #1
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1161
Practice Address - Country:US
Practice Address - Phone:920-886-9319
Practice Address - Fax:920-886-9357
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI128-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39274100Medicaid