Healthcare Provider Details

I. General information

NPI: 1033464920
Provider Name (Legal Business Name): KATHERINE PETERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 TAMAL PLZ STE 235
CORTE MADERA CA
94925-1070
US

IV. Provider business mailing address

200 TAMAL PLZ STE 235
CORTE MADERA CA
94925-1070
US

V. Phone/Fax

Practice location:
  • Phone: 415-496-5105
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY28781
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: