MEDICARE: DR. TARA JEAN PETERSON PSYD

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	103G00000X	Clinical Neuropsychologist	35302	CA

General Provider Information

NPI Number	:	1598354128
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TARA JEAN PETERSON PSYD

Provider Business Mailing Address
First Line	:	10 VERONA LN
Second Line	:
City	:	FOOTHILL RANCH
State	:	CA
Zip	:	92610-1913
Country	:	US
Telephone Number	:	949-616-4809
Fax Number	:

Provider Business Practice Location Address
First Line	:	10085 CARROLL CANYON RD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92131-1138
Country	:	US
Telephone Number	:	858-208-3463
Fax Number	:

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

Provider Enumeration Date	:	01/18/2021
Last Update Date	:	09/10/2024

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