Individual
DR. JOHN ANTHONY PETERSEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PSY.D.
Contact information
Practice address
922 E WAYNE ST # 205, SOUTH BEND, IN 46617-3024
(574) 280-8199
Mailing address
208 E ANGELA BLVD, SOUTH BEND, IN 46617-1202
(574) 288-7919
(574) 280-8199
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
20041594A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200347860A
—
IN
Enumeration date
09/23/2006
Last updated
12/01/2018
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