Basic Information
| Provider Information | |||||||||
| NPI: | 1104199074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | TANDICE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5021 CAMDEN ST | ||||||||
| Address2: | |||||||||
| City: | CHUBBUCK | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832023501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086040624 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 353 S 4TH AVE SUITE 1 | ||||||||
| Address2: | STE 1 | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832015100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082337832 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2012 | ||||||||
| LastUpdateDate: | 01/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.