Provider Demographics
NPI:1083122840
Name:PETERSON, BERTHA MARIA
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:MARIA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4940 SOMERVILLE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-6716
Mailing Address - Country:US
Mailing Address - Phone:423-707-8542
Mailing Address - Fax:407-960-3009
Practice Address - Street 1:415 HIBISCUS BLVD
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-5070
Practice Address - Country:US
Practice Address - Phone:321-961-7831
Practice Address - Fax:407-960-3009
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-15
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty