Provider Demographics
NPI:1548259658
Name:PETERS, CYNTHIA LEE (PHD)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LEE
Last Name:PETERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:LEE
Other - Last Name:DESTICHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:416 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-2755
Mailing Address - Country:US
Mailing Address - Phone:262-567-7673
Mailing Address - Fax:262-567-3097
Practice Address - Street 1:416 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-2755
Practice Address - Country:US
Practice Address - Phone:262-567-7673
Practice Address - Fax:262-567-3097
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39343100Medicaid
P13363Medicare UPIN