Healthcare Provider Details

I. General information

NPI: 1760138432
Provider Name (Legal Business Name): CYNTHIA PETERSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2022
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 MENAUL BLVD NE STE B
ALBUQUERQUE NM
87110-4639
US

IV. Provider business mailing address

7700 MENAUL BLVD NE STE B
ALBUQUERQUE NM
87110-4639
US

V. Phone/Fax

Practice location:
  • Phone: 505-967-8470
  • Fax:
Mailing address:
  • Phone: 505-967-8470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY-2025-0011
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY16476
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: