Provider Demographics
NPI:1114074242
Name:PETERSON, JOSEPH KEITH (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:KEITH
Last Name:PETERSON
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 1:621 PACIFIC AVE
Mailing Address - Street 2:100
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-4600
Mailing Address - Country:US
Mailing Address - Phone:253-572-2588
Mailing Address - Fax:253-572-3356
Practice Address - Street 1:621 PACIFIC AVE
Practice Address - Street 2:100
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4600
Practice Address - Country:US
Practice Address - Phone:253-572-2588
Practice Address - Fax:253-572-3356
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1232103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical