Provider Demographics
NPI:1417592742
Name:PETERSON, KATHERINE (PHD, LEP)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHD, LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 UNIVERSITY DR STE 103
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-4447
Mailing Address - Country:US
Mailing Address - Phone:650-248-7609
Mailing Address - Fax:
Practice Address - Street 1:1150 UNIVERSITY DR STE 103
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4447
Practice Address - Country:US
Practice Address - Phone:650-248-7609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3231103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool