MEDICARE: DR. KIRSTEN E PETERSEN 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	103TC0700X	Clinical Psychologist	021715	NY
2	103TC0700X	Clinical Psychologist	P95464	NY

General Provider Information

NPI Number	:	1831581594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIRSTEN E PETERSEN PHD

Provider Business Mailing Address
First Line	:	2389 BABYLON ST
Second Line	:
City	:	WANTAGH
State	:	NY
Zip	:	11793-4501
Country	:	US
Telephone Number	:	917-991-1042
Fax Number	:

Provider Business Practice Location Address
First Line	:	2389 BABYLON ST
Second Line	:
City	:	WANTAGH
State	:	NY
Zip	:	11793-4501
Country	:	US
Telephone Number	:	917-991-1042
Fax Number	:

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

Provider Enumeration Date	:	03/04/2015
Last Update Date	:	10/09/2020

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