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Provider Information for 1861688608


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Dr. RYAN W PETERSON Psy.D.


Sex: Male

NPI: 1861688608
Last Updated: 2012-07-24
Certification Date:

Details

NameValue
NPI1861688608
Enumeration Date2007-09-14
NPI TypeNPI-1 Individual
Sole ProprietorYES
StatusActive
Mailing Address 115 LIBERTY ST
BATH, NY 14810-1508
United States

Phone: 607-776-6577 | Fax:607-664-2161
 
Primary Practice Address 115 LIBERTY ST
BATH, NY 14810-1508
United States

Phone: 607-776-6577 | Fax:607-664-2161
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
No 101YM0800X - Counselor - Mental Health
Yes 103T00000X - Psychologist NY019091-1