Provider Demographics
NPI:1760138432
Name:PETERSON, CYNTHIA (PHD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
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 1:2999 REGENT ST.
Mailing Address - Street 2:#601
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705
Mailing Address - Country:US
Mailing Address - Phone:510-843-2005
Mailing Address - Fax:
Practice Address - Street 1:2999 REGENT ST.
Practice Address - Street 2:#601
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705
Practice Address - Country:US
Practice Address - Phone:510-843-2005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16476103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist