Healthcare Provider Details

I. General information

NPI: 1144860917
Provider Name (Legal Business Name): MELISSA EDWARDS PETERSEN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 MONTGOMERY ST
FORT WORTH TX
76107-2553
US

IV. Provider business mailing address

855 MONTGOMERY ST
FORT WORTH TX
76107-2553
US

V. Phone/Fax

Practice location:
  • Phone: 817-735-2200
  • Fax:
Mailing address:
  • Phone: 817-735-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number36939
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number36939
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: