MEDICARE: DR. PATRICIA LOY PETTERSON PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PSY 17370	CA

General Provider Information

NPI Number	:	1558707398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PATRICIA LOY PETTERSON PH.D.

Provider Business Mailing Address
First Line	:	349 CEDAR ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-3112
Country	:	US
Telephone Number	:	619-231-2828
Fax Number	:	619-234-1465

Provider Business Practice Location Address
First Line	:	349 CEDAR ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-3112
Country	:	US
Telephone Number	:	619-231-2828
Fax Number	:	619-234-1465

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2013
Last Update Date	:	05/20/2013

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