Provider Demographics
NPI:1740340678
Name:PETERSON, POLLY A (PHD)
Entity type:Individual
Prefix:DR
First Name:POLLY
Middle Name:A
Last Name:PETERSON
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 1:1406 E FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-7404
Mailing Address - Country:US
Mailing Address - Phone:208-331-1936
Mailing Address - Fax:208-331-1937
Practice Address - Street 1:1406 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-7404
Practice Address - Country:US
Practice Address - Phone:208-331-1936
Practice Address - Fax:208-331-1937
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCOUN-50101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health