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NPI Code Detail

MEDICARE: KATHRYN PETERSEN MA

MEDICARE: KATHRYN PETERSEN MA
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
1103K00000XBehavior Analyst1-13-14878CA

General Provider Information

NPI Number : 1487084091
Entity Type Code : Individual
Provider Name (Legal Business Name) : KATHRYN PETERSEN MA
Provider Business Mailing Address
First Line : 13325 CALLE DEL CAMPO UNIT 2
Second Line :
City : SAN DIEGO
State : CA
Zip : 92129-4687
Country : US
Telephone Number : 858-361-0670
Fax Number :
Provider Business Practice Location Address
First Line : 6540 LUSK BLVD STE C256
Second Line :
City : SAN DIEGO
State : CA
Zip : 92121-5795
Country : US
Telephone Number : 858-657-9117
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/18/2013
Last Update Date : 11/18/2013

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Directions to “ KATHRYN PETERSEN MA” Practice Location

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