Provider Demographics
NPI:1760799217
Name:PIETERSE, ALEX L (PHD)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:L
Last Name:PIETERSE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 N ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-1633
Mailing Address - Country:US
Mailing Address - Phone:301-523-6031
Mailing Address - Fax:
Practice Address - Street 1:925 BROADWAY
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12207-1306
Practice Address - Country:US
Practice Address - Phone:301-523-6031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-04
Last Update Date:2010-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018552-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist