Provider Demographics
NPI:1417600511
Name:PETERSON, MARK (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9033 ACORN RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-5413
Mailing Address - Country:US
Mailing Address - Phone:916-798-7072
Mailing Address - Fax:
Practice Address - Street 1:8911 LAKEWOOD DR # 26A
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CA
Practice Address - Zip Code:95492-7856
Practice Address - Country:US
Practice Address - Phone:916-798-7072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94026068103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA18611570000Medicaid