Provider Demographics
NPI:1679742928
Name:PETERSON, RODERICK DEJUAN SR (MA, LLPC, CAAC, CCSM)
Entity type:Individual
Prefix:MR
First Name:RODERICK
Middle Name:DEJUAN
Last Name:PETERSON
Suffix:SR
Gender:M
Credentials:MA, LLPC, CAAC, CCSM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7845 MIDDLEBELT RD STE 201
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-2174
Mailing Address - Country:US
Mailing Address - Phone:734-721-0900
Mailing Address - Fax:
Practice Address - Street 1:7845 MIDDLEBELT RD STE 201
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-2174
Practice Address - Country:US
Practice Address - Phone:734-721-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIS-10019101YA0400X
MIC-00234101YA0400X
MI1972368101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)