Provider Demographics
NPI:1053845453
Name:PEDERSEN, LOREN ELIOT (PHD)
Entity Type:Individual
Prefix:DR
First Name:LOREN
Middle Name:ELIOT
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2363 BOULEVARD CIR
Mailing Address - Street 2:SUITE 7
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94595-1177
Mailing Address - Country:US
Mailing Address - Phone:925-963-9780
Mailing Address - Fax:
Practice Address - Street 1:2363 BOULEVARD CIR
Practice Address - Street 2:SUITE 7
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94595-1177
Practice Address - Country:US
Practice Address - Phone:925-963-9780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4958103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist