Provider Demographics
NPI:1356589683
Name:PEDERSEN, ANNELISA HELENE (PHD)
Entity type:Individual
Prefix:
First Name:ANNELISA
Middle Name:HELENE
Last Name:PEDERSEN
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 1:2222 WESTERN TRAILS BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1601
Mailing Address - Country:US
Mailing Address - Phone:512-815-3814
Mailing Address - Fax:
Practice Address - Street 1:2222 WESTERN TRAILS BLVD STE 107
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1601
Practice Address - Country:US
Practice Address - Phone:512-815-3814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38061103TC0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1356589683OtherBCBSTX