Provider Demographics
NPI:1669917399
Name:PETERSON, GEORGE A (PHD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:A
Last Name:PETERSON
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:PO BOX P
Mailing Address - Street 2:20 SANCHEZ RD STE P
Mailing Address - City:FOREST KNOLLS
Mailing Address - State:CA
Mailing Address - Zip Code:94933-0713
Mailing Address - Country:US
Mailing Address - Phone:415-488-4855
Mailing Address - Fax:
Practice Address - Street 1:PO BOX P
Practice Address - Street 2:20 SANCHEZ RD STE P
Practice Address - City:FOREST KNOLLS
Practice Address - State:CA
Practice Address - Zip Code:94933-0713
Practice Address - Country:US
Practice Address - Phone:415-488-4855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22173103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist