Provider Demographics
NPI:1861577165
Name:PETERSON, ROSS D
Entity type:Individual
Prefix:MR
First Name:ROSS
Middle Name:D
Last Name:PETERSON
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 1:1724 BONITA AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-2810
Mailing Address - Country:US
Mailing Address - Phone:847-437-1357
Mailing Address - Fax:
Practice Address - Street 1:1610 LUTHER LN
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1243
Practice Address - Country:US
Practice Address - Phone:847-795-3166
Practice Address - Fax:847-823-9222
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional