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General NPI Number Information
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NPI Number | 1083831408
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Entity Type | Organization
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Legal Business Name | LELAND W. PETERSEN, PSYCHOLOGIST, P.C.
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Dates
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Enumeration Date | 04/19/2007
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Last Update Date | 06/17/2008
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Provider Practice Location Address
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Address Line | 11 BEECHWOOD DR
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City | GLEN HEAD
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State | NY
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Zip | 11545-1101
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Country | US
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Telephone | 516-671-7509
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Fax |
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Provider Business Mailing Address
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Address Line | 11 BEECHWOOD DR
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City | GLEN HEAD
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State | NY
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Zip | 11545-1101
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Country | US
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Telephone | 516-671-7509
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LELAND WALTER PETERSEN
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Credential | PH.D.
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Telephone | 516-671-7509
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 05430
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License Number State | NY
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