Provider Demographics
NPI:1790902229
Name:PETERSEN, LELAND W (CP)
Entity Type:Individual
Prefix:
First Name:LELAND
Middle Name:W
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BEECHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-1101
Mailing Address - Country:US
Mailing Address - Phone:516-671-7509
Mailing Address - Fax:
Practice Address - Street 1:11 BEECHWOOD DR
Practice Address - Street 2:
Practice Address - City:GLEN HEAD
Practice Address - State:NY
Practice Address - Zip Code:11545-1101
Practice Address - Country:US
Practice Address - Phone:516-671-7509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05430103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV50231Medicare PIN