Healthcare Provider Details

I. General information

NPI: 1235266016
Provider Name (Legal Business Name): PETER VIETZE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 04/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 GRAND ST 3RD FLOOR
NEW YORK NY
10002-4800
US

IV. Provider business mailing address

957 CEDARBROOK RD
PLAINFIELD NJ
07060-2646
US

V. Phone/Fax

Practice location:
  • Phone: 347-668-4992
  • Fax: 212-420-1910
Mailing address:
  • Phone: 347-668-4992
  • Fax: 908-757-8322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number017065
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: