Provider Demographics
NPI:1346665882
Name:BETSY PEDERSEN PHD PC
Entity Type:Organization
Organization Name:BETSY PEDERSEN PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:919-923-3278
Mailing Address - Street 1:1502 W NC HIGHWAY 54
Mailing Address - Street 2:SUITE 603
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-5571
Mailing Address - Country:US
Mailing Address - Phone:919-923-3278
Mailing Address - Fax:919-419-3110
Practice Address - Street 1:1502 W NC HIGHWAY 54
Practice Address - Street 2:SUITE 603
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-5571
Practice Address - Country:US
Practice Address - Phone:919-923-3278
Practice Address - Fax:919-419-3110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1808261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2815321BOtherMEDICARE PTAN
NC1808OtherPRACTICE LICENSE -PSYCHOLOGIST
NC60008531DMedicaid