Healthcare Provider Details

I. General information

NPI: 1962424044
Provider Name (Legal Business Name): REBECCA JANE PETERSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 12/25/2025
Certification Date: 12/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N WASHINGTON ST # 314
FALLS CHURCH VA
22046-3452
US

IV. Provider business mailing address

400 N WASHINGTON ST # 314
FALLS CHURCH VA
22046-3452
US

V. Phone/Fax

Practice location:
  • Phone: 703-798-5748
  • Fax: 703-894-3392
Mailing address:
  • Phone: 703-798-5748
  • Fax: 703-894-3392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0810003663
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number0810003663
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810003663
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: