Healthcare Provider Details

I. General information

NPI: 1104632991
Provider Name (Legal Business Name): KATRINA LAREA PETTERSEN LEP 4489
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1261 LINCOLN AVE STE 104
SAN JOSE CA
95125-3030
US

IV. Provider business mailing address

2893 UNION AVE
SAN JOSE CA
95124-1435
US

V. Phone/Fax

Practice location:
  • Phone: 408-439-1111
  • Fax:
Mailing address:
  • Phone: 760-902-8990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number4489
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: