Provider Demographics
NPI:1295737898
Name:PETERSEN, TIMOTHY J (PHD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:PETERSEN
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 1:1 BOWDOIN SQ
Mailing Address - Street 2:7TH FLOOR, OFFICE 744
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2927
Mailing Address - Country:US
Mailing Address - Phone:617-643-0262
Mailing Address - Fax:617-726-2992
Practice Address - Street 1:1 BOWDOIN SQ
Practice Address - Street 2:7TH FLOOR, OFFICE 744
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2927
Practice Address - Country:US
Practice Address - Phone:617-643-0262
Practice Address - Fax:617-726-2992
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7731103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0503002Medicaid
MA0503002Medicaid