Provider Demographics
NPI:1194038752
Name:PETERSON, KAREN LYNNE (MA)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:LYNNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3272 BLACK AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-1033
Mailing Address - Country:US
Mailing Address - Phone:805-582-4889
Mailing Address - Fax:
Practice Address - Street 1:72 MOODY CT STE 201
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-7427
Practice Address - Country:US
Practice Address - Phone:805-981-4221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-23
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent