Provider Demographics
NPI:1164634986
Name:PETERS, JOELLEN M (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOELLEN
Middle Name:M
Last Name:PETERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 ALTA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-3151
Mailing Address - Country:US
Mailing Address - Phone:512-627-1308
Mailing Address - Fax:512-440-5747
Practice Address - Street 1:1810 ALTA VISTA AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-3151
Practice Address - Country:US
Practice Address - Phone:512-627-1308
Practice Address - Fax:512-440-5747
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3-1552103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical