Provider Demographics
NPI:1366498263
Name:PETERSEN, ANTJE (MFT)
Entity Type:Individual
Prefix:
First Name:ANTJE
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 609001
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92160-9001
Mailing Address - Country:US
Mailing Address - Phone:619-528-4600
Mailing Address - Fax:619-528-4625
Practice Address - Street 1:450 FOURTH AVENUE
Practice Address - Street 2:STE 215
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-4428
Practice Address - Country:US
Practice Address - Phone:619-498-5454
Practice Address - Fax:619-528-4625
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC420872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry