Provider Demographics
NPI:1871616169
Name:COE, PETER J (PHD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:COE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 DUNHAM RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1498
Mailing Address - Country:US
Mailing Address - Phone:630-377-2790
Mailing Address - Fax:
Practice Address - Street 1:475 DUNHAM RD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1498
Practice Address - Country:US
Practice Address - Phone:630-377-2790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL102L00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL200522Medicare ID - Type Unspecified