Provider Demographics
NPI:1518941384
Name:PETERSEN, BETH M (PSY D HSPP)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:M
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PSY D HSPP
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:M
Other - Last Name:ALDERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD HSPP
Mailing Address - Street 1:PO BOX 3868
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47737-3868
Mailing Address - Country:US
Mailing Address - Phone:812-426-9779
Mailing Address - Fax:812-426-6610
Practice Address - Street 1:421 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47713-1227
Practice Address - Country:US
Practice Address - Phone:812-426-9779
Practice Address - Fax:812-426-6610
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042022A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200806070Medicaid
IN371620OtherMHN TRICARE
IN371620OtherMHN TRICARE