Healthcare Provider Details

I. General information

NPI: 1982107959
Provider Name (Legal Business Name): PETERSON PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2018
Last Update Date: 03/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 ALPINE CIR
COLUMBIA SC
29223-6385
US

IV. Provider business mailing address

125 ALPINE CIR
COLUMBIA SC
29223-6385
US

V. Phone/Fax

Practice location:
  • Phone: 803-779-3548
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1271
License Number StateSC

VIII. Authorized Official

Name: DR. MICHELLE PETERSON
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PH.D.
Phone: 803-779-3548