Provider Demographics
NPI:1598244576
Name:PETERS, JUDITH ANN (PHD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:PETERS
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 1:15420 SMOLAND LN NE
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-1040
Mailing Address - Country:US
Mailing Address - Phone:206-818-9573
Mailing Address - Fax:
Practice Address - Street 1:15420 SMOLAND LN NE
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-1040
Practice Address - Country:US
Practice Address - Phone:206-818-9573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60150527101Y00000X
WA601-505-272084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No101Y00000XBehavioral Health & Social Service ProvidersCounselor