Provider Demographics
NPI:1730890401
Name:PETERSEN, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 BEN FRANKLIN HWY W
Mailing Address - Street 2:
Mailing Address - City:DOUGLASSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19518-1829
Mailing Address - Country:US
Mailing Address - Phone:610-385-3155
Mailing Address - Fax:
Practice Address - Street 1:1125 BEN FRANKLIN HWY W
Practice Address - Street 2:
Practice Address - City:DOUGLASSVILLE
Practice Address - State:PA
Practice Address - Zip Code:19518-1829
Practice Address - Country:US
Practice Address - Phone:610-385-3155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-13
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health