Provider Demographics
NPI:1568870046
Name:PETERSEN VENTURA, NYSSA (PHD)
Entity Type:Individual
Prefix:
First Name:NYSSA
Middle Name:
Last Name:PETERSEN VENTURA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 ORONDO AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2800
Mailing Address - Country:US
Mailing Address - Phone:509-662-6000
Mailing Address - Fax:509-664-4590
Practice Address - Street 1:504 ORONDO AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2830
Practice Address - Country:US
Practice Address - Phone:509-884-9047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60719603103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2038116Medicaid