Provider Demographics
NPI:1679061519
Name:PETERSON, CHRISTIAN B
Entity type:Individual
Prefix:MR
First Name:CHRISTIAN
Middle Name:B
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 STOCKHOLM ST APT 2C
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-3265
Mailing Address - Country:US
Mailing Address - Phone:718-902-1219
Mailing Address - Fax:
Practice Address - Street 1:93 STOCKHOLM ST APT 2C
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-3265
Practice Address - Country:US
Practice Address - Phone:718-902-1219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator