Individual
MR. RUSSELL HENRY PETERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.S.
Contact information
Practice address
2375 E SUNNYSIDE RD, SUITE C, IDAHO FALLS, ID 83404-8280
(208) 529-5777
(208) 529-5778
Mailing address
4360 E 278 N, RIGBY, ID 83442-5892
(208) 359-4775
(208) 356-5461
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
LCPC-3125
ID
Other
Enumeration date
12/20/2006
Last updated
07/08/2007
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