Provider Demographics
NPI:1306012919
Name:PETERSON, RENA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RENA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:RENA
Other - Middle Name:
Other - Last Name:STACY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:466 WOLDUNN CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5914
Mailing Address - Country:US
Mailing Address - Phone:561-702-9216
Mailing Address - Fax:
Practice Address - Street 1:1971 LEE RD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-1870
Practice Address - Country:US
Practice Address - Phone:407-450-8151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-03
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7702103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist