John Anthony Petersen, PSY.D.

Primary specialty

PsychologistTaxonomy code 103T00000X

License

20041594A Issued in IN

Practice address

922 E Wayne St # 205
South Bend, IN 46617-3024

Phone

(574) 280-8199

NPI assigned

Sep 23, 2006

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Family Psychology of South Bend LLC

  dba Family Psychology of South Bend

  • Family Psychologist
  • South Bend, IN
  • NPI 1083184196
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1158969600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1543622400000",
    "number": "1851491526",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "208 E ANGELA BLVD",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466171202",
            "telephone_number": "574-288-7919",
            "fax_number": "574-280-8199"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "922 E WAYNE ST # 205",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466173024",
            "telephone_number": "574-280-8199"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "115 S Saint Peter St",
            "address_purpose": "LOCATION",
            "city": "South Bend",
            "state": "IN",
            "postal_code": "466172912",
            "country_code": "US",
            "telephone_number": "574-280-8199",
            "fax_number": "574-280-8199",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PETERSEN",
        "first_name": "JOHN",
        "middle_name": "ANTHONY",
        "name_prefix": "Dr.",
        "credential": "PSY.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-09-23",
        "last_updated": "2018-12-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "IN",
            "license": "20041594A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200347860A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Ashley Person
• Molly Pestow, NP
• Leslie M Peters, FNP
• Mathew Peters, LCSW
• Shianne Peters
• Sarah Petersen
• Faye Peterson-Pottinger, LCSW
• Charles E Peterson, MD
• Michelle Nicole Peterson, RDN
• Shotunus Denean Peterson, M.S.W

• Psychologist in South Bend, IN
• Providers in South Bend, IN by specialty
• Psychologist in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 1, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.