Provider Demographics
NPI:1457717613
Name:PETERSON, TIM (PSYD)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:PETERSON
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 1:119 IRVINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-4217
Mailing Address - Country:US
Mailing Address - Phone:210-760-3577
Mailing Address - Fax:
Practice Address - Street 1:4940 BROADWAY STE 330
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-5744
Practice Address - Country:US
Practice Address - Phone:210-588-0298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37292103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical