Individual
DR. GARY GLEN PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PH.D.
Contact information
Practice address
675 SUN VALLEY ROAD, C, KETCHUM, ID 83340
(208) 928-6555
(208) 928-7666
Mailing address
PO BOX 3441, SUN VALLEY, ID 83353-3441
(208) 928-6555
(208) 928-7666
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
578
AZ
103T00000X
Psychologist
7790
CA
103T00000X
Psychologist
Primary
PSY 202479
ID
Other
Enumeration date
05/07/2007
Last updated
08/05/2010
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