MEDICARE: DR. KATHLEEN GERYL PETERSEN 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	PYRO278	MO

General Provider Information

NPI Number	:	1518023803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHLEEN GERYL PETERSEN PH.D.

Provider Business Mailing Address
First Line	:	7106 DALE AVE
Second Line	:
City	:	RICHMOND HEIGHTS
State	:	MO
Zip	:	63117-1927
Country	:	US
Telephone Number	:	314-647-5522
Fax Number	:	314-827-0067

Provider Business Practice Location Address
First Line	:	7106 DALE AVENUE
Second Line	:
City	:	ST. LOUIS
State	:	MO
Zip	:	63117-1927
Country	:	US
Telephone Number	:	314-647-5522
Fax Number	:	314-827-0067

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

Provider Enumeration Date	:	12/29/2006
Last Update Date	:	07/12/2010

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