Healthcare Provider Details

I. General information

NPI: 1326202516
Provider Name (Legal Business Name): ASHLEY MARIE PETERSEN PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 04/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 MAIN ST STE D
PARK RIDGE IL
60068-4060
US

IV. Provider business mailing address

509 W 10TH ST
ANTIOCH CA
94509-1653
US

V. Phone/Fax

Practice location:
  • Phone: 847-823-4444
  • Fax:
Mailing address:
  • Phone: 925-777-9540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: