Provider Demographics
NPI:1700295326
Name:PETERSON, MILTON JR (LCDC)
Entity type:Individual
Prefix:MR
First Name:MILTON
Middle Name:
Last Name:PETERSON
Suffix:JR
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2353 AVENUE M APT 29
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340-5752
Mailing Address - Country:US
Mailing Address - Phone:936-439-5746
Mailing Address - Fax:
Practice Address - Street 1:5711 LAVENDER ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77026-1725
Practice Address - Country:US
Practice Address - Phone:713-557-8573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLCDC#696101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)