MEDICARE: ANNELISA HELENE PEDERSEN PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	38061	TX
2	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1356589683	OTHER	TX	BCBSTX

General Provider Information

NPI Number	:	1356589683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNELISA HELENE PEDERSEN PHD

Provider Business Mailing Address
First Line	:	2222 WESTERN TRAILS BLVD STE 107
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78745-1601
Country	:	US
Telephone Number	:	512-815-3814
Fax Number	:

Provider Business Practice Location Address
First Line	:	2222 WESTERN TRAILS BLVD STE 107
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78745-1601
Country	:	US
Telephone Number	:	512-815-3814
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2009
Last Update Date	:	06/22/2022

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