Provider Demographics
NPI:1538480389
Name:PETERSEN, ERIK J (BCBA)
Entity type:Individual
Prefix:
First Name:ERIK
Middle Name:J
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:30 SANDY BEACH RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-3283
Mailing Address - Country:US
Mailing Address - Phone:508-295-2721
Mailing Address - Fax:
Practice Address - Street 1:321 FORTUNE BLVD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-1750
Practice Address - Country:US
Practice Address - Phone:508-478-0207
Practice Address - Fax:508-634-6984
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA042197449OtherTRICARE