Provider Demographics
NPI:1083831408
Name:LELAND W. PETERSEN, PSYCHOLOGIST, P.C.
Entity Type:Organization
Organization Name:LELAND W. PETERSEN, PSYCHOLOGIST, P.C.
Other - Org Name:L.W. PETERSEN, PSYCHOLOGIST, P.C.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LELAND
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:516-671-7509
Mailing Address - Street 1:11 BEECHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-1101
Mailing Address - Country:US
Mailing Address - Phone:516-671-7509
Mailing Address - Fax:
Practice Address - Street 1:11 BEECHWOOD DR
Practice Address - Street 2:
Practice Address - City:GLEN HEAD
Practice Address - State:NY
Practice Address - Zip Code:11545-1101
Practice Address - Country:US
Practice Address - Phone:516-671-7509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05430103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWXRWZ1Medicare PIN