Provider Demographics
NPI:1164633632
Name:PETERSEN, DAVID (PHD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:A
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:14724 LOCUSTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20905-6424
Mailing Address - Country:US
Mailing Address - Phone:301-388-0650
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF MARYLAND
Practice Address - Street 2:1209 SHOEMAKER BUILDING
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20742-0001
Practice Address - Country:US
Practice Address - Phone:301-314-9792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03772101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health