Provider Demographics
NPI:1861765174
Name:PETERSON, DENISE (MED, BCBA)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 BELMONT RD
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-4804
Mailing Address - Country:US
Mailing Address - Phone:401-741-7394
Mailing Address - Fax:
Practice Address - Street 1:66 BELMONT RD
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-4804
Practice Address - Country:US
Practice Address - Phone:401-741-7394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI0-06-2164103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst