Provider Demographics
NPI:1295107415
Name:PETERSEN, OWEN PATRICK (PSYD)
Entity type:Individual
Prefix:DR
First Name:OWEN
Middle Name:PATRICK
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 PURDUE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3104
Mailing Address - Country:US
Mailing Address - Phone:424-442-0813
Mailing Address - Fax:
Practice Address - Street 1:1531 PURDUE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3104
Practice Address - Country:US
Practice Address - Phone:424-442-0813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27756103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical