Provider Demographics
NPI:1023178761
Name:PETERSON, LINDA M (CP)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 MAPLETON AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-4263
Mailing Address - Country:US
Mailing Address - Phone:303-449-9494
Mailing Address - Fax:303-447-6453
Practice Address - Street 1:3445 PENROSE PL
Practice Address - Street 2:SUITE 250
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1877
Practice Address - Country:US
Practice Address - Phone:303-449-9494
Practice Address - Fax:303-447-6453
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1220103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07012206Medicaid
CO07012206Medicaid