Provider Demographics
NPI:1598085813
Name:PETERSEN, CHRISTIE (MED, LBA)
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MED, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11623 ANGUS RD STE 20
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-4041
Mailing Address - Country:US
Mailing Address - Phone:512-827-7011
Mailing Address - Fax:512-382-1190
Practice Address - Street 1:11623 ANGUS RD STE 20
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759
Practice Address - Country:US
Practice Address - Phone:512-827-7011
Practice Address - Fax:512-382-1190
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1378103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst