MEDICARE: DR. GRACE ELAINE BARBARA PETERSON 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	103T00000X	Psychologist	PSY34164	CA

General Provider Information

NPI Number	:	1518657154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRACE ELAINE BARBARA PETERSON PHD

Provider Business Mailing Address
First Line	:	8875 AERO DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-2251
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3350 LA JOLLA VILLAGE DR # 116KM
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92161-2251
Country	:	US
Telephone Number	:	858-833-5931
Fax Number	:

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

Provider Enumeration Date	:	05/08/2023
Last Update Date	:	05/08/2023

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