MEDICARE: DR. TRICA L. PETERSON PH.D.

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	103T00000X	Psychologist	017446	NY
2	103TF0200X	Forensic Psychologist	017446	NY

General Provider Information

NPI Number	:	1477839223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRICA L. PETERSON PH.D.

Provider Business Mailing Address
First Line	:	675 PANORAMA TRL W
Second Line	:	SUITE 12
City	:	ROCHESTER
State	:	NY
Zip	:	14625-2406
Country	:	US
Telephone Number	:	585-563-8284
Fax Number	:

Provider Business Practice Location Address
First Line	:	675 PANORAMA TRL W
Second Line	:	SUITE 12
City	:	ROCHESTER
State	:	NY
Zip	:	14625-2406
Country	:	US
Telephone Number	:	585-563-8284
Fax Number	:

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

Provider Enumeration Date	:	10/25/2011
Last Update Date	:	11/05/2024

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