Provider Demographics
NPI:1386858942
Name:PETERSON, DAVID BRIAN (PHD, HSP)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRIAN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHD, HSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6272 BLUE SAGE LOOP
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32829-7425
Mailing Address - Country:US
Mailing Address - Phone:626-487-3875
Mailing Address - Fax:407-386-3089
Practice Address - Street 1:6272 BLUE SAGE LOOP
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32829-7425
Practice Address - Country:US
Practice Address - Phone:626-487-3875
Practice Address - Fax:407-386-3089
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2024-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY12174103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA29649097OtherTPIN
CA788777360OtherDUNS
CA1088-11-90090OtherBPA FOR SSA ODAR