Provider Demographics
NPI:1639361736
Name:PETERSON, THOMAS R (PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7910 BOSQUE ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-1201
Mailing Address - Country:US
Mailing Address - Phone:505-982-8870
Mailing Address - Fax:505-982-0620
Practice Address - Street 1:1441 S SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4037
Practice Address - Country:US
Practice Address - Phone:505-982-2177
Practice Address - Fax:505-982-0620
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM0931103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical