Provider Demographics
NPI:1043862543
Name:PETERSON, JOSHUA JAMES (RBT)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:JAMES
Last Name:PETERSON
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 PAOLI PIKE APT 92
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-5178
Mailing Address - Country:US
Mailing Address - Phone:812-267-9523
Mailing Address - Fax:
Practice Address - Street 1:2702 PAOLI PIKE APT 92
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-5178
Practice Address - Country:US
Practice Address - Phone:812-267-9523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INBACB380326106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty