Healthcare Provider Details

I. General information

NPI: 1639361736
Provider Name (Legal Business Name): THOMAS R. PETERSON PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 02/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 S SAINT FRANCIS DR
SANTA FE NM
87505-4037
US

IV. Provider business mailing address

7910 BOSQUE ST NW
ALBUQUERQUE NM
87114-1201
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-2177
  • Fax: 505-982-0620
Mailing address:
  • Phone: 505-982-8870
  • Fax: 505-982-0620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0931
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: